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Articles In Press

Articles In Press

Letters to the Editor (Limit 700 words) (commentary on previous published WestJEM papers)

Comments on “A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke”

Door-in-door-out (DIDO) time has been considered an important factor for prognostication in large vessel occlusion stroke (LVOS) patients. Recently, Sigal et al. have concluded in their paper, “A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke,” that DIDO was not an independent risk factor for worse outcomes following LVOS. In this letter to the editor, we argue that DIDO time should still be considered an important prognosticator for outcomes in LVOS, despite not being found to be significant in their multivariable analysis. Despite our concerns, we wholeheartedly agree with the authors that clinicians should still need to expedite patients who have LVOS to undergo thrombectomy, regardless of where they are during the critical period of time.

Brief Research Report

Preventive Health Services Offered in a Sampling of US Emergency Departments, 2022–2023

Introduction: In the United States, more chronic and preventive healthcare is being delivered in the emergency department (ED) setting. Understanding the availability of preventive health services in the ED setting is crucial. Our goal was to understand the availability of a subset of preventive health services in US EDs and explore how that has changed over time.

Methods: In 2022–2023, using the National Emergency Department Inventory (NEDI)-USA, we surveyed a random 20% (1,064) sampling of all 5,613 US EDs. We asked directors of these EDs about the availability of and preference for 12 preventive health services, social worker availability, self-reported percentage of uninsured ED patients, and measures of ED crowding. We also asked about perceptions of barriers to implementing preventive health services in the ED. We used unadjusted and multivariable logistic regression models to compare service frequency in 2022–2023 to prior findings from 2008–2009 that represented a 5.7% random sampling of all EDs.

Results: Among 302 responders to the 2022–2023 survey (5.4% random sampling, 28.4% response rate), 94% reported offering at least one preventive health service, with a median of five services. The most common service offered was intimate partner violence screening (83%), while the least common was routine HIV screening (19%). Seven services (eg, intimate partner violence, alcohol risk, and smoking cessation screening) had a higher odds of being offered in 2022–2023 than in 2008–2009; findings were unchanged in sensitivity analyses. A small proportion of directors opposed offering preventive health services. However, many expressed concerns that preventive health services in the ED would lead to longer lengths of stay (56%), increased costs to their ED (58%), a diversion of staff time from providing acute care (50%), or that their patients would not have access to adequate follow-up (49%).

Conclusion: Nearly all EDs offer at least one preventive health service. Many offer multiple services; rates were higher than those identified in 2008–2009, in both unadjusted and multivariable models. Although limited by the response rate, this work provides the most recent and comprehensive snapshot of the type and frequency of a subset of preventive health services currently offered in US EDs.

  • 2 supplemental ZIPs

Review Article (Limit 4000 words)

Scoping Review: Is Push-Dose Norepinephrine a Better Choice?

Introduction: The use of push-dose vasopressors to treat anesthesia-induced hypotension is a common evidence-based practice among anesthesiologists. In more recent years, the use of push-dose vasopressors has transitioned to the emergency department (ED) and critical care setting. There is debate on the best choice of a push-dose vasopressor, with push-dose epinephrine or phenylephrine being more commonly used. This scoping review evaluated publications regarding the clinical use of push-dose norepinephrine.

Methods: We queried research studies in both PubMed and Google Scholar on the use of push-dose norepinephrine in human subjects, with numerous randomized controlled trials that compare norepinephrine to other vasopressors including phenylephrine, ephedrine, and epinephrine.

Results: A large majority of the studies were performed in the setting of spinal anesthesia prior to cesarean section, while several involved the administration of general anesthesia, with limited-to-no literature in the emergency and critical care setting. Of the 27 studies that we included in the review, 17 were randomized controlled trials. These studies demonstrated that norepinephrine was safe and effective.

Conclusion: Prior research has demonstrated the superiority of norepinephrine as a pressor of choice for various shock states. In this review, the safety and efficacy of push-dose norepinephrine is demonstrated, and favorable hemodynamic markers are shown in comparison to other agents. In addition, there are some safety and efficiency benefits to using push-dose norepinephrine from an administration standpoint, as well as clinically in decreased need for repeat doses. Further high-quality studies in the emergency and critical care realm would be beneficial to confirm these findings.

Original Research (Limit 4000 words)

Exploring Medical Student Experiences of Trauma in the Emergency Department: Opportunities for Trauma-informed Medical Education

Purpose: During the third-year emergency medicine (EM) clerkship, medical students are immersed in traumatic incidents with their patients and clinical teams. Trauma-informed medical education (TIME) applies trauma-informed care (TIC) principles to help students manage trauma. We aimed to qualitatively describe the extent to which students perceived the six TIME domains as they navigated critical incidents during their EM clerkship.

Methods: We employed a constructivist, modified grounded theory approach to explore medical students’ experiences. We used the critical incident technique to elicit narratives to better understand the six TIME domains as they naturally appear in the clerkship. Participants were asked to describe a traumatic incident they experienced during the clerkship, followed by the clerkship’s role in helping them manage the incident. Using the framework method, transcripts were analyzed 1) deductively by matching transcript excerpts to relevant TIME domains and 2) inductively by generating de novo themes to capture factors that affected students’ handling of trauma during critical incidents.

Results: Twelve participants were enrolled and interviewed in July 2022. “Safety” was the most frequently described TIME domain, whereas “Gender, Cultural, and Historical issues” and “Peer Support” were discussed least. Inductive analysis revealed themes that hindered or supported their ability to manage traumatic experiences, which were grouped into three categories: 1) student interactions with the learning environment: complex social determinants of health, inequalities in care, and overt discrimination; 2) student interactions with patients: ethically ambiguous care, witnessing acute patient presentations, and reactivation of past trauma; and 3) student interactions with supervisors: power dynamics, invalidation of contributions, role-modeling, and student empowerment.

Conclusion: The six TIME domains are represented in students’ perceptions of immediate, stressful critical incidents during their EM clerkship, with “Safety” being the most commonly described; however, the degree to which these domains are supported in students’ experiences of the EM clerkship differ, and instances of inadequately experienced domains may contribute to student distress. Understanding the EM clerkship through the specific lens of students’ experiences of trauma may be an effective strategy to guide curricular changes that promote a supportive learning environment for students in the emergency department.

Impact of Prehospital Ultrasound Training on Simulated Paramedic Clinical Decision-Making

Introduction: When used appropriately, focused limited-scope ultrasound exams could potentially provide paramedics with accurate and actionable diagnostic information to guide prehospital decision-making. In this study we aimed to investigate the impact of a 13-hour prehospital ultrasound training course on the simulated clinical decision-making of paramedics as well as their ultrasound skills, knowledge, and self-confidence.

Methods: We evaluated the ultrasound competence of 31 participants using post-course written and practical assessments. Written clinical decision scenarios were administered pre- and post-training. Post-training scenarios included an uninterpreted ultrasound clip to aid decision-making. Scenarios included extended focused assessment with sonography in trauma, pulmonary exam, and focused echocardiography combined with carotid pulse check exams. Correct answers to scenarios were defined as those selected by a veteran emergency physician. Participants also indicated their confidence in each of their decisions using a Likert scale.

Results: Training yielded a statistically significant increase in both mean scenario score (35.5%absolute increase) and mean participant self-confidence (15.8% relative increase), across all exam/decision types assessed (P ≤ 0.001). The focused pulmonary exam yielded the largest increase in both mean score improvement (59.7% absolute increase) and paramedic confidence in their decisions (28.6% increase).

Conclusion: Trained paramedics can perform focused ultrasound exams and accurately interpret and apply actionable exam findings in the context of written scenarios. Analysis through our model characterized the theoretical clinical yield of each prehospital ultrasound exam and demonstrated how each exam may provide improved decision accuracy in several specific simulated clinical contexts. These results provide support for growing evidence that focused limited-scope ultrasound may be an effective prehospital diagnostic tool in the hands of trained paramedics.

  • 2 supplemental ZIPs

Neutrophil-to-Lymphocyte Ratio Predicts Sepsis in Adult Patients Meeting Two or More Systemic Inflammatory Response Syndrome Criteria

Introduction: Determining which patients who meet systemic inflammatory response syndrome (SIRS) criteria have bacterial sepsis is a difficult challenge for emergency physicians. We sought to determine whether the neutrophil-to-lymphocyte ratio (NLR) could be used to exclude bacterial sepsis in adult patients who meet ≥2 SIRS criteria and are being evaluated for sepsis.

Methods: Consenting adult patients meeting ≥2 SIRS criteria and undergoing evaluation for sepsis were enrolled. We recorded patient age, gender, vital signs, and laboratory results. We then later reviewed health records for culture results, end organ dysfunction, survival to discharge, and final diagnoses.
Patients were classified as having sepsis if they met ≥2 SIRS criteria and were ultimately diagnosed with a bacterial source. We analyzed data using descriptive statistics and sensitivity and specificity analyses. A receiver operating characteristic curve (ROC) was created to determine test characteristics.

Results: A total of 231 patients had complete datasets. Patients’ median age was 69 (interquartile range [IQR] 54–81), and 49.6% were male. There were 154 patients (66.7%) ultimately diagnosed with sepsis with an identified bacterial source, while 77 patients with ≥2 SIRS criteria had non-infectious reasons for their presentations (33.3%). Septic patients had a median NLR 12.36 (IQR [interquartile range] 7.29–21.69), compared to those without sepsis (median NLR 5.62, IQR 3.89–9.11, P < 0.001). The NLR value of 3 applied as a cutoff for sepsis had a sensitivity of 96.8 (95% confidence interval [CI] 92.2–98.8), and a specificity of 18.2 (95% CI 10.6–29.0). The ROC for NLR had an area under the curve of 0.74.

Conclusion: The neutrophil-to-lymphocyte ratio is a sensitive tool to help determine which patients with abnormal SIRS screens have bacterial sepsis.

Emergency Department Blood Pressure Treatment and Outcomes in Adults Presenting with Severe Hypertension

Background: Patients who present to the emergency department (ED) with severe hypertension defined as a systolic blood pressure (SBP) ≥180 millimeters of mercury (mm Hg) or diastolic (DBP) ≥120 (mm Hg) without evidence of acute end-organ damage are often deemed high risk and treated acutely in the ED. However, there is a dearth of evidence from large studies with long-term follow-up for the assessment of major adverse cardiovascular events (MACE). We conducted the largest study to date of patients presenting with severe hypertension to identify predictors of MACE and examine whether blood pressure at discharge is associated with heightened risk.

Methods: We enrolled ED patients with a SBP of 180–220 mm Hg but without signs of end-organ damage and followed them for one year. The primary outcome was MACE within one year of discharge. Secondarily, we performed a propensity-matched analysis to test whether SBP ≤160 mm Hg at discharge was associated with reduced MACE at 30 days.

Results: A total of 12,044 patients were enrolled. The prevalence of MACE within one year was 1,865 (15.5%). Older age, male gender, history of cardiovascular disease, cerebrovascular disease, diabetes, smoking, presentation with chest pain, altered mental status, dyspnea, treatment with intravenous and oral hydralazine, and oral metoprolol were independent predictors for one-year MACE. Additionally, discharge with an SBP ≤160 mm Hg was not associated with 30-day MACE-free survival after propensity matching (hazard ratio 0.99, 95% confidence interval 0.78–1.25, P = 0.92).

Conclusion: One-year MACE was relatively common in our cohort of ED patients with severe hypertension without acute end-organ damage. However, discharge blood pressure was not associated with 30-day or one-year MACE, suggesting that BP reduction in and of itself is not beneficial in such patients.

  • 1 supplemental ZIP

Systematic Review (Limit 4000 words)

Impact of Medical Trainees on Efficiency and Productivity in the Emergency Department: Systematic Review and Narrative Synthesis

Introduction: Effective medical education must balance clinical service demands for institutions and learning needs of trainees. The question of whether these are competing demands or can serve complementary roles has profound impacts on graduate medical education, ranging from funding decisions to the willingness of community-based hospitals and physicians to include learners at their clinical sites. Our objective in this article was to systematically review the evidence on the impact of medical trainees on productivity and efficiency in the emergency department (ED).

Methods: We queried PubMed, Embase, Scopus, and Web of Science from earliest available dates to March 2023. We identified all studies evaluating the impact of medical students and/or residents in the ED on commonly used productivity and efficiency metrics. Only studies in EDs in the United States were included. No additional filters were used. We assessed the risk of bias of included studies using the Risk of Bias in Non-randomized Studies – of Interventions (ROBINS-I) tool. Certainty of evidence was rated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Study findings were combined in a narrative synthesis and reported according to PRISMA guidelines.

Results: The literature search yielded 3,390 unique articles for abstract screening. Eighty-one abstracts were identified as relevant to our PICO question (population, intervention, control, and outcomes), 76 of which had retrievable full-text articles and the themes of which were discussed in a narrative synthesis. We selected 13 of the full-text articles for final inclusion in a systematic review. Studies were roughly split between observational (6) and quasi-experimental (7) designs. The majority of studies (11) were single-site studies. Only two studies could be graded as low risk of bias per the ROBINS-I tool.

Conclusion: Low-GRADE evidence suggests that students and residents decrease ED efficiency by a statistically small effect size of debatable clinical importance. Residents provide a moderate boost to ED productivity. Students do not produce a statistically or clinically significant impact on ED productivity. Residents increase emergency department relative value units revenue by $26.30 an hour, while students have no impact. Both types of learners decrease efficiency.

  • 1 supplemental ZIP

Brief Research Report (Limit 1500 words)

Enroller Experience and Parental Familiarity of Disease Influence Participation in a Pediatric Trial

Introduction: Acquiring parental consent is critical to pediatric clinical research, especially in interventional trials. In this study we investigated demographic, clinical, and environmental factors associated with likelihood of parental permission for enrollment in a study of therapies for diabetic ketoacidosis (DKA) in children. Methods: We analyzed data from patients and parents who were approached for enrollment in the Pediatric Emergency Care Applied Research Network (PECARN) Fluid Therapies Under Investigation in DKA (FLUID) trial at one major participating center. We determined the influence of various factors on patient enrollment, including gender, age, distance from home to hospital, insurance status, known vs new onset of diabetes, glycemic control (hemoglobin A1c), DKA severity, gender of the enroller, experience of the enroller, and time of enrollment. Patients whose parents consented to participate were compared to those who declined participation using bivariable and multivariable analyses controlling for the enroller. Results: A total of 250 patient/parent dyads were approached; 177 (71%) agreed to participate, and 73 (29%) declined. Parents of patients with previous episodes of DKA agreed to enroll more frequently than those with a first DKA episode (94.3% for patients with 1-2 previous DKA episodes, 92.3% for > 2 previous episodes, vs 64.9% for new onset diabetes and 63.2% previously diagnosed but no previous DKA). Participation was also more likely with more experienced enrollers (odds ratio [95% confidence interval] of participation for an enroller with more than two years’ experience vs less than two years: 2.46 [1.53, 3.97]). After adjusting for demographic and clinical factors, significant associations between participation and both DKA history and enroller experience remained. Patient age, gender, distance of home from hospital, glycemic control, insurance status, and measures of DKA severity were not associated with likelihood of participation. Conclusion: Familiarity with the disease process (previously diagnosed diabetes and previous experience with DKA) and experience of the enroller favorably influenced the likelihood of parental permission for enrollment in a study of DKA in children.

Images in Emergency Medicine (Limit 500 words)

Evolving Paralysis after Motor Vehicle Collision

Case Presentation An 85-year-old male presented to the emergency department after a motor vehicle collision and developed progressive neurological deficits.  CT imaging demonstrated epidural thickening from C2-C7, and MRI was notable for a cervicothoracic epidural hematoma.  The patient underwent emergent decompression with a favorable outcome. Discussion Cases of traumatic spinal epidural hematomas are rarely seen in the emergency department.  These are part of a small subset of operative neurological emergencies that benefit from urgent operative intervention.

A Strange Twist

Case presentation. A 16-year-old female presented to the emergency department with a four-day history of right lower quadrant abdominal pain for several hours. The patient was afebrile and physical examination was notable for isolated tenderness in the right lower quadrant. Ultrasound and computed tomography demonstrated an adnexal cystic structure. Pelvic magnetic resonance imaging was ordered to better characterize the pathology. Discussion. Isolated fallopian tube torsion is an uncommon entity requiring prompt surgical intervention. Recognition and appropriate management are essential.

Nail gun injury of the trachea and spinal cord

Case Presentation A 26-year-old man was impaled by a nail after a nail gun accident. He was fully conscious with weakness and loss of sensation in the extremities. Cervical computed tomography showed a 9-cm long nail penetrating the spinal cord. The nail was removed 6 hours after the incident. The neurological deficits gradually improved, and at the 3-month follow-up, the patient had completely recovered from muscle weakness. Discussion The present case showed a favorable neurological course, which was be attributable to the fact that the cervical spinal cord injury did not involve the corticospinal tracts and anterior horn.

Omental Prolapse Through Vaginal Cuff Dehiscence

ABSTRACT A 31-year old female with a history of laparoscopic assisted vaginal hysterectomy presented by ambulance to the emergency department with acute onset of abdominal pain and a vaginal protrusion which occurred while straining to pass a bowel movement.  Physical examination was notable for a flat but slightly tender abdomen, normal bowel sounds, scant vaginal bleeding, and a 15cm long, blood-tinged mass protruding from the vagina.  A brief and unsuccessful attempt at reduction was made by the emergency physician.  Obstetrics and Gynecology was consulted, and the patient was taken to the operating DIAGNOSIS Omental prolapse through vaginal cuff dehiscence .  Following vaginal hysterectomy, the vaginal cuff is closed surgically1.  Occasionally, this site can dehisce, allowing abdominal contents to enter the vagina or protrude through the vaginal canal. Vaginal cuff dehiscence is estimated to have a rate of 0.39%. It is more commonly seen after total laparoscopic hysterectomy (1.35%) compared with laparoscopic-assisted vaginal hysterectomy, (0.28%)2. Risk factors include trauma from sexual intercourse, repetitive Valsalva maneuvers, smoking, malnutrition, anemia, diabetes, immunosuppression, and corticosteroid use2.  Cases typically present as vaginal spotting or post-coital bleeding, and occasionally pelvic pressure or protrusion2.  Most cases occur within weeks to months after the procedure, but some can present years later. Patients are at risk for infection due to exposure of peritoneal contents to vaginal and skin flora.  Management includes administration of broad-spectrum antibiotics.  Partial dehiscence can be managed with rest, but large dehiscence is usually managed surgically. This case highlights the importance of the pelvic exam in patients with vaginal bleeding and abdominal pain, and care should be taken to not mistake protruding omental tissue for prolapsed vaginal mucosa.   REFERENCES 1.     Binz NM, et al. Complications of Gynecologic Procedures. Emergency Medicine: A Comprehensive Study Guide , 9e. McGraw Hill; 2020. 2.     Clarke-Pearson D, & Geller E. Complications of Hysterectomy.  Obstetrics & Gynecology, 121 (3), 654-673; 2013.

Table of Contents

Articles in Press

Once articles have been accepted for publication but have not yet been assigned to an issue, we place them here.

Case Report (Limit 1750 words)

Pheochromocytoma: A Diagnosis Made More Difficult in the COVID-19 Era

ABSTRACT INTRODUCTION Pheochromocytomas and paragangliomas are rare neuroendocrine tumors that secrete catecholamines. Symptoms of these tumors are related directly to catecholamine excess but can be intermittent and easily misattributed to other more common pathologies.  Identification in the Emergency Department is inherently difficult.  In the COVID-19 pandemic physicians have had to account for both the disease itself as well as associated increased prevalence of cardiac, pulmonary, and vascular complications. Such shifting of disease prevalence arguably makes rarer diseases, like pheochromocytoma, less likely to be recognized. CASE REPORT We report a case of pheochromocytoma discovered in the emergency department in a patient who presented with fatigue, tachycardia, and diaphoresis. The differential included pulmonary embolism, cardiomyopathy, congestive heart failure and infectious causes.  A broad workup was begun including serology, electrocardiogram, Computed Tomography Angiogram (CTA), and COVID-19 testing. This patient was evaluated in the winter of 2020, the local height of the COVID-19 pandemic, and was found to be positive.  A tiny retroperitoneal tumor was reported on CTA as “incidental” in the setting of multifocal pneumonia from COVID-19 infection. But further history taking discovered many years of intermittent symptoms and suggested that the tumor may be more contributory to the patient’s presentation. Subsequent MRI and surgical pathology confirmed the pheochromocytoma. CONCLUSION This case presentation highlights the importance of careful history taking, keeping a broad differential, and examining incidental findings in the context of the patient’s presentation.

Case Report: Pancreatitis, with a Normal Serum Lipase, as a Rare Post-Esophagogastroduodenoscopy Complication

Pancreatitis after Esophagogastroduodenoscopy (EGD) is not a common occurrence, particularly in the setting of a normal serum lipase. The lack of commonality may delay diagnosis and treatment in some patients presenting to the emergency department with abdominal pain after an otherwise uncomplicated procedure. This case report serves to bring awareness to this potential procedural complication and the possibility of pancreatitis with a normal serum lipase.

Takotsubo cardiomyopathy following traumatic hand amputation

Takotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease. We describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point of care ultrasound (POCUS) associated with traumatic hand amputation.  The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition ten days later. Emergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

Hypotension unresponsive to fluid resuscitation: A Case Report

Introduction: Iron deficiency anemia is commonly seen in the emergency department, and the cause can be complex and variable.  Chronic lice infestation as the etiology of severe iron deficiency anemia has not been well studied and is mostly limited to case reports. Case Report: We present a case of a female without known medical history who presented to the emergency department for generalized weakness and was found to have severe anemia in the setting of chronic lice infestation.  This patient’s hypotension was initially unresponsive to fluid resuscitation which allowed for consideration of other etiologies of this patient’s presentation and an unusual case of severe anemia. Conclusion: Severe and chronic pediculosis can cause chronic blood loss and be an unusual and rare cause of iron deficiency anemia.  In the setting of anemia and hypotension unresponsive to fluid resuscitation, consideration should be given to early PRBC transfusion and subsequent investigation of causes of severe anemia.

Occipital Lobe Status Epilepticus; A Rare Stroke Mimic with Novel Imaging Findings: A Case Report

Introduction This case reviews a patient who presented to the emergency department (ED) with homonymous hemianopsia, a rare manifestation of partial status epilepticus of the occipital lobe.  Her initial brain computerized axial tomographic (CT) perfusion scan and magnetic resonance imaging (MRI) revealed novel findings associated with this diagnosis. Case Report A 70-year-old female presented to our ED with left visual field hemianopsia, dyskinesia, dysmetria and facial droop . Her initial diagnosis was left posterior fossa circulation cerebrovascular accident.  However, her neuroimaging indicated hypervascularity of the left occipital lobe without evidence of infarct or structural lesion. A cerebral angiogram excluded arterio-venous malformation.  Subsequently, an electroencephalogram showed left occipital lobe status epilepticus.   Conclusion Hemianopsia is a rare presentation of partial status epilepticus mimicking stroke.  Hypervascularity seen on advanced neuroimaging may have suggested this diagnosis on initial ED evaluation.