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Open Access Publications from the University of California

Volume 13, Issue 6, 2012

Work Force Education

Does Targeted Education of Emergency Physicians Improve Their Comfort Level in Treating Psychiatric Patients?

Introduction: We determined if targeted education of emergency physicians (EPs)regarding the treatment of mental illness will improve their comfort level in treatingpsychiatric patients boarding in the emergency department (ED) awaiting admission.

Methods: We performed a pilot study examining whether an educational interventionwould change an EP’s comfort level in treating psychiatric boarder patients (PBPs). Weidentified a set of psychiatric emergencies that typically require admission or treatmentbeyond the scope of practice of emergency medicine. Diagnoses included majordepression, schizophrenia, schizoaffective disorder, bipolar affective disorder, generalanxiety disorder, suicidal ideation, and criminal behavior. We designed equivalentsurveys to be used before and after an educational intervention. Each survey consistedof 10 scenarios of typical psychiatric patients. EPs were asked to rate their comfort levelsin treating the described patients on a visual analogue scale. We calculated summaryscores for the non intervention survey group (NINT) and intervention survey group (INT)and compared them using Student’s t-test.

Results: Seventy-nine percent (33/42) of eligible participants completed the preinterventionsurvey (21 attendings, 12 residents) and comprised the NINT group. Fiftyfivepercent (23/42) completed the post-intervention survey (16 attendings, 7 residents)comprising the INT group. A comparison of summary scores between ‘NINT’ and ‘INT’groups showed a highly significant improvement in comfort levels with treating thepatients described in the scenarios (P = 0.003). Improvements were noted on separateanalysis for faculty (P = 0.039) and for residents (P = 0.012). Results of a sensitivityanalysis excluding one highly significant scenario showed decreased, but still importantdifferences between the NINT and INT groups for all participants and for residents, butnot for faculty (all: P = 0.05; faculty: P = 0.25; residents: P = 0.03).

Conclusion: This pilot study suggests that the comfort level of EPs, when asked to treatPBPs, may be improved with education. We believe our data support further study of thisidea and of whether an improved comfort level will translate to a willingness to treat.[West J Emerg Med. 2012;13(6):453-457]

  • 3 supplemental PDFs
  • 1 supplemental file

Factors Affecting Candidate Placement on an Emergency Medicine Residency Program’s Rank Order List

Introduction: Several factors influence the final placement of a medical student candidate on anemergency medicine (EM) residency program’s rank order list, including EM grade, standardized letterof recommendation, medical school class rank, and US Medical License Examination (USMLE) scores.We sought to determine the correlation of these parameters with a candidate’s final rank on a residencyprogram’s rank order list.

Methods: We used a retrospective cohort design to examine 129 candidate packets from an EMresidency program. Class ranks were assessed according to the instructions provided by the students’medical schools. EM grades were scored from 1 (honors) to 5 (fail). Global assessments noted on the standardized letter of recommendation (SLOR) were scored from 1 (outstanding) to 4 (good). USMLEscores were reported as the candidate’s 3-digit scores. Spearman’s rank correlation coefficient wasused to analyze data.

Results: Electronic Residency Application Service packets for 127/129 (98.4%) candidates wereexamined. The following parameters correlated positively with a candidate’s final placement on therank order list: EM grade, q¼0.379, P , 0.001; global assessment, q¼0.332, P , 0.001; and classrank, q¼0.234, P¼0.035. We found a negative correlation between final placement on the rank orderlist with both USMLE step 1 scores, q¼0.253, P¼0.006; and USMLE step 2 scores, q¼0.348, P¼0.004.

Conclusion: Higher scores on EM rotations, medical school class ranks, and SLOR globalassessments correlated with higher placements on a rank order list, whereas candidates with higherUSMLE scores had lower placements on a rank order list. However, none of the parameters examined correlated strongly with ultimate position of a candidate on the rank list, which underscores that otherfactors may influence a candidate’s final ranking. [West J Emerg Med. 2012;13(6):458–462.]

Emergency Department Access

How Long Are Patients Willing to Wait in the Emergency Department Before Leaving Without Being Seen?

Introduction: Our goal was to evaluate patients’ threshold for waiting in an emergency department(ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness towait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status.

Methods: We conducted this survey-based study from March to July 2010 at an urban academicmedical center. After triage, patients were given a multiple-choice questionnaire, designed toascertain how long they would wait for medical care. We collected data including age, gender, race,insurance status, and triage acuity level. We looked at the association between willingness to waitand these variables, using stratified analysis and logistic regression.

Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventyone(51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and110 (32%) would wait indefinitely. No association was found between willingness to wait and race,gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended tobe older than 25, have higher acuity, and prefer the study site ED.

Conclusion: Many patients have a defined, limited period that they are willing to wait for emergencycare. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED withoutbeing seen. This result suggests that efforts to reduce the percentage of patients who LWBS mustfactor in time limits. [West J Emerg Med. 2012;13(6):463-467]

  • 1 supplemental PDF

Medical Decision Making

Family History is a Predictor for Appendicitis in Adults Presenting to the Emergency Department

Introduction: A family history of appendicitis has been reported to increase the likelihood of thediagnosis in children and in a retrospective study of adults. We compare positive family history with thediagnosis of acute appendicitis in a prospective sample of adults.

Methods: We conducted a prospective observational study of a convenience sample of 428 patients.We compared patients with surgically proven appendicitis to a group without appendicitis. The latterwere further grouped by their presenting symptoms: those presenting with a chief complaint ofabdominal pain and those with other chief complaints. Participants answered questions regarding theirfamily history of appendicitis. Family history was then compared for the appendicitis group versus thenonappendicitis group as a whole, and then versus the subgroup of patients without appendicitis butwith abdominal pain. The primary analysis was a v2 test of proportions and the calculation of odds ratio(OR) for the relationship between final diagnosis of appendicitis and family history.

Results: Of 428 patients enrolled, 116 had appendicitis. Of those with other diagnoses, 158 hadabdominal pain and 154 had other complaints. Of all patients with appendicitis, 37.9% (confidence interval [CI]=29.1–46.8) had positive family history. Of those without appendicitis, 23.7% (CI=19.0–28.4) had positive family history. In the subgroup without appendicitis but with abdominal pain, 25.9%(CI=19.1–32.8) had positive family history. Both comparisons were significant (P=0.003; OR=1.97;95% CI=1.2–3.1; and P=0.034; OR=1.74; 95% CI=1.04–2.9, respectively). By multivariate logisticregression analysis across the full sample, family history was a significant independent predictor (P=0.011; OR = 1.883) of appendicitis.

Conclusion: Adults presenting to the emergency department with a known family history ofappendicitis are more likely to have this disease than those without. [West J Emerg Med.2012;13(6):468–471.]

Procedural Safety

Current Trends in the Management of Difficult Urinary Catheterizations

Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands orother potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failedcatheterization and concomitant complications increase. Repeated and unsuccessful attempts aturinary catheterization induce stress and pain for the patient, injury to the urethra, potential urethralstricture requiring surgical reconstruction, and problematic subsequent catheterization. Improperinsertion of catheters also can significantly increase healthcare costs due to added days ofhospitalization, increased interventions, and increased complexity of follow-up evaluations. Improved techniques for catheter placement are essential for all healthcare personnel involved in themanagement of the patient with acute urinary retention, including attending emergency physicians whooften are the first physicians to encounter such patients. Best practice methods for blind catheter placement are summarized in this review. In addition, for progressive clinical practice, an algorithm forthe management of difficult urinary catheterizations that incorporates technology enabling directvisualization of the urethra during catheter insertion is presented. This algorithm will aid healthcare personnel in decision making and has the potential to improve quality of care of patients. [West J EmergMed. 2012;13(6):472–478.]

  • 1 supplemental PDF

Diagnostic Acumen

Persistent Hiccups as a Rare Presenting Symptom of Pulmonary Embolism

Pulmonary embolism (PE) is a life-threatening condition that may present as dyspnea, chest pain,cough or hemoptysis, but often occurs without symptoms. It is not typically associated with hiccups.Hiccups are generally self-limiting benign contractions of the diaphragm that may be associatedwith medications or food but may also be symptomatic of serious disease when persistent. Wereport 3 cases of PE presenting as persistent hiccups. [West J Emerg Med. 2012;13(6):479-483]

Takayasu’s Arteritis- An Unusual Cause of Stroke in a Young Patient

We describe the case of a 28-year-old-male with no significant medical history who presented with right-sided hemiparesis, bruits over the carotid and subclavian arteries and an elevated erythrocyte sedimentation rate. Imaging studies revealed a middle cerebral artery thrombus and inflammatory changes of the carotid and subclavian arteries and aorta. The diagnosis of Takayasu’s arteritis was made and the patient was started on steroids and immunomodulators with good clinical response. [West J Emerg Med. 2012;13(6):484-487]

Unusual Presentation of Toxoplasma Gondii Encephalitis

We report a case of altered mental status secondary to acute Toxoplasma Gondii encephalitis. The patient had no medical or surgical history and presented with acute onset of lethargy with no clear precipitant. A physical exam revealed no focal neurological deficits and a subsequent medicalworkup revealed multiple intracranial lesions with a biopsy confirming the diagnosis of Toxoplasma Gondii encephalitis in the setting of newly diagnosed human immunodeficiency virus (HIV). A literature review revealed that this is a unique case of toxoplasmic encephalopathy in the United States in a previously undiagnosed HIV positive patient presenting to an emergency department. [West J Emerg Med. 2012;13(6):488-490]

Chief Complaint: Right Hip Pain

A interesting case and image of a 50-year-old woman with a history of non-insulin diabetes mellitus (NIDDM) who presented to the emergency department with right hip pain for one week and the subsequent findings. [West J Emerg Med. 2012;13(6):494]

Left Upper Quadrant Abdominal Pain


We present a case of acute appendicitis from mobile cecum presenting with left upper quadrant abdominal pain. [West J Emerg Med. 2012;13(6):495-496]

What’s Eating Your Wishbone? Sternoclavicular Septic Arthritis with Osteomyelitis

This manuscript describes the presentation of a patient with sternoclavicular joint infection, with a brief discussion on the diagnosis and treatment of this rare septic arthritis. [West J Emerg Med. 2012;13(6):497-498]

An Uncommon Case of Abdominal Pain: Superior Mesenteric Artery Syndrome

Superior mesenteric artery (SMA) syndrome is a rare cause of abdominal pain, nausea and vomiting that may be undiagnosed in patients presenting to the emergency department (ED). We report a 54-year-old male presenting to a community ED with abdominal pain and the subsequent radiographic findings.The patient’s computed tomgraphy (CT) of the abdomen and pelvis demonstrates many of the hallmark findings consistent with SMA syndrome, including; compression of the duodenum between the abdominal aorta and superior mesenteric artery resulting in intestinal obstruction, dilation of the left renal vein, and gastric distension. Patients diagnosed with SMA syndrome have a characteristically short distance between the superior mesenteric artery and the aorta (usually 2–8 mm) in contrast to healthy patients (10–34 mm). Our patient’s aortomesenteric distance was measured to be approximately 4 mm. Furthermore, the measured angle between the superior mesenteric artery and the aorta is reduced in patients withSMA syndrome from a normal range of 28°–65° to a measurement between 6°–22°. Our patient’s aortomesenteric angle was difficult to measure secondary to poor sagittal reconstructions, but appears to be approximately 30°. Following radiographic evidence suggesting SMA syndrome together with our patient’s constellation of presenting symptoms, a diagnosis of SMA syndrome was made and the patient was admitted to the general surgery service. However, our patient decided to leave against medical advice owing to improvement of his symptoms following the emptying of two liters of gastric contents via nasogastric tube evacuation. [West J Emerg Med. 2012;13(6):501-502]


Severe Neck Pain with Fever: Is it Meningitis?

A 58-year-old male patient presented to the emergency department with complaints of severe neck pain. He admitted to drug use but denied using intravenous (IV) drugs. On exam, he had a fever of 100.7 F, positive Kernig’s sign, and normal neurologic exam. The patient was suspected to have bacterial meningitis and was started on IV antibiotics. The next day the patient developed decreased hand grip. Magnetic resonance imaging of the spine the next day showed a soft-tissue mass impinging on the spinal canal. The patient was subsequently taken to the operating room where the epidural abscess was drained. [West J Emerg Med. 2012;13(6):505–506.]

Asterixis as a Presentation of Cerebellar Ischemic Stroke

Asterixis is not yet considered a common neurological sign of cerebellum infarction, and the pathogenic mechanism for asterixis remains elusive. We report a 58-year-old male with moderate hypertension who presented to our emergency department for acute headache in both cervical and occipital regions of the left side. About 2 hours later the patient developed ipsilateral asterixis in the upper left limb; 3 days later the asterixis disappeared. Magnetic resonance imaging of the brain disclosed cerebellarinfarctions at the left superior cerebellar artery. In conclusion, we observed that a transitory asterixis associated with ipsilateral headache can be an initial clinical manifestation of ipsilateral cerebellar infarctions in the superior cerebellar artery area. [West J Emerg Med. 2012;13(6):507-508]

Subdural Empyema Presenting with Seizure, Confusion, and Focal Weakness

While sinusitis is a common ailment, intracranial suppurative complications of sinusitis are rare and difficult to diagnose and treat. The morbidity and mortality of intracranial complications of sinusitis have decreased significantly since the advent of antibiotics, but diseases such as subduralempyemas and intracranial abscesses still occur, and they require prompt diagnosis, treatment, and often surgical drainage to prevent death or long-term neurologic sequelae. We present a case of an immunocompetent adolescent male with a subdural empyema who presented with seizures,confusion, and focal arm weakness after a bout of sinusitis. [West J Emerg Med. 2012;13(6):509-511]

Electrocardiogram changes in thyrotoxic periodic paralysis

Thyrotoxic periodic paralysis (TPP) attacks are characterized as recurrent, transient episodes of muscle weakness that range from mild weakness to complete flaccid paralysis. Episodes of weakness are accompanied by hypokalemia, which left untreated can lead to life-threatening arrhythmias (6). In this case study, we followed a patient’s potassium levels analyzing how they correlate with electrocardiogram changes seen while treating his hypokalemia and ultimately his paralysis. [West J Emerg Med. 2012;13(6):512-513]

Technology in Emergency Care

Ultrasound Diagnosis of Urethral Calculi

This images case demonstrates the utility of bedside focused ultrasound performed by the Emergency Physician in making the accurate diagnosis of an impacted urethral stone. [West J Emerg Med. 2012;13(6):515]

  • 1 supplemental video

Pulmonary Hypertension, Hemoptysis and an Echocardiographic Finding of a Ventricular Septal Defect

In this case presentation, a patient who presented to the Emergency Department with hemoptysis and shortness of breath was found to have a ventricular septal defect and right ventricular strain on bedside ultrasound. This case leads to a discussion of Eisenmenger Syndrome, a potentially ominous development in a patient with these clinical and ultrasound findings. [West J Emerg Med. 2012;13(6):516]

  • 2 supplemental videos

Bladder Bulge: Unifying Old and New Sonographic Bladder Wall Abnormalities in Ureterolithiasis

As long as CT remains the first line imaging modality in suspected ureterolithiasis, emergency physicians will continue to perform the majority of renal colic ultrasound studies in a search for hydronephrosis. Hydronephrosis, however, is not always present and emergency physicians may not find it as useful as would be expected. Through this case series of seven patients, we present what we believe to be commonly present and easily acquired sonographic bladder wall findings in ureterolithiasis. These abnormalities are not routinely taught in emergency ultrasound and have not been reported in the emergency medicine literature. One variant, in fact, may be a novel finding unto itself. Due to their similar appearance, we propose to unify these findings under the name “bladder bulge.” This sign can be seen on axial views as an inward bulging or focal thickening of the bladder wall on the affected side, at the uretovesical junction. [West J Emerg Med. 2012;13(6):517-523]

Sonographic Consensual Pupillary Reflex

Patients suffering from severe orbital trauma are at risk for numerous complications, including orbital compartment syndromes. This can result in an afferent pupillary defect, which must be evaluated for on physical examination. Unfortunately, these at-risk patients are often challengingto examine properly due to surrounding edema. Point-of-care ultrasonography can be used as an adjunct to the standard examination in this situation. [West J Emerg Med. 2012;13(6):524]

  • 1 supplemental video

Transjugular Intrahepatic Portosystemic Shunt (TIPS) Migration to the Heart Diagnosed by Emergency Department Ultrasound

A 57-year-old man presented to our emergency department with altered mental status. He had a past medical history significant for cirrhosis and previous placement of a transjugular intrahepatic portosystemic shunt (TIPS). On cardiac auscultation, a new heart murmur and an unexpected degree of cardiac ectopy were noted. On the 12-lead electrocardiogram, the patient was noted to have multiple premature atrial contractions, corroborating the irregular heart rhythm on physicalexam. A focused bedside emergency ultrasound of the heart was then performed. This exam revealed an apparent foreign body in the right atrium. It appeared as if the patient’s TIPS had migrated from the heart into the right atrium. This case, as well as the literature describing thisunusual complication of TIPS placement, is reviewed in this case report. [West J Emerg Med. 2012;13(6):525-526]

  • 2 supplemental videos

Burden of Chronic Disease

Grade III or Grade IV Hypertensive Retinopathy with Severely Elevated Blood Pressure

Introduction: Hypertensive retinopathy describes a spectrum of retinal changes in patients with elevated blood pressure (BP). It is unknown why some patients are more likely to develop acute ocular end-organ damage than others with similar BP. We examined risk factors for grade III/IV hypertensive retinopathy among patients with hypertensive urgency in the emergency department (ED) and compared healthcare utilization and mortality between patients with and without grade III/IVhypertensive retinopathy.

Methods: A preplanned subanalysis of patients who presented to a university hospital ED with diastolic BP 120 mmHg and who enrolled in the Fundus Photography versus Ophthalmoscopy Trial Outcomes in the ED study was performed. Bilateral nonmydriatic ocular fundus photographs, vital signs, and demographics were obtained at presentation. Past medical history, laboratory values, healthcare utilization, and mortality were ascertained from medical record review at least 8 months after initial ED visit.

Results: Twenty-one patients with diastolic BP 120 mmHg, 7 of whom (33%) had grade III/IV hypertensive retinopathy, were included. Patients with retinopathy were significantly younger than those without (median 33 vs 50 years, P ¼ 0.02). Mean arterial pressure (165 vs 163 mmHg) was essentially equal in the 2 groups. Patients with retinopathy had substantially increased but nonsignificant rates of ED revisit (57% vs 29%, P ¼ 0.35) and hospital admission after ED discharge (43% vs 14%, P ¼ 0.28). One of the patients with retinopathy died, but none without.

Conclusion: Younger patients may be at higher risk for grade III/IV hypertensive retinopathy among patients with hypertensive urgency. Chronic compensatory mechanisms may have not yet developedin these younger patients. Alternatively, older patients with retinopathy may be underrepresented secondary to increased mortality among these patients at a younger age (survivorship bias). Further research is needed to validate these preliminary findings. [West J Emerg Med. 2012;13(6):529–534.]

  • 1 supplemental PDF
  • 3 supplemental images
  • 1 supplemental file


Holiday Plants with Toxic Misconceptions

Several plants are used for their decorative effect during winter holidays. This review exploresthe toxic reputation and proposed management for exposures to several of those, namelypoinsettia (Euphorbia pulcherrima), English holly (Ilex aquifolium), American holly (Ilex opaca),bittersweet (Solanum dulcamara), Jerusalem cherry (Solanum pseudocapsicum), Americanmistletoe (Phoradendron serotinum), and European mistletoe (Viscum album). [West J Emerg Med.2012;13(6):538-542]


Visual Hallucinations: Charles Bonnet Syndrome

The following is a case of Charles Bonnet syndrome in an 86-year-old woman who presented with visualhallucinations. The differential diagnosis of visual hallucinations is broad and emergency physicians shouldbe knowledgeable of the possible etiologies. [West J Emerg Med. 2012;13(6):544-547]

Increase in Non-Contrast Computerized Tomography Scans of the Head Following Popular Media Stories About Head Injury

Introduction: On March 18, 2009, actress Natasha Richardson died after a head injury. It is possiblethat the rate of patients presenting with mild head injury and receiving computed tomographies (CTs)may have been influenced by the Richardson event. We hypothesized that there was a statisticallysignificant increase in the rate of census-adjusted head CTs performed for mild trauma after March16, 2009, compared to prior to this date.

Methods: We included all with a non-contrast head CT performed from the emergency department(ED) between March 1and April 15, 2009, for minor trauma. The primary outcome was the censusadjustedrate of head CTs per time (# of head CTs/census). We compared the census adjusted ratefor the 2 weeks prior to 2 weeks after the accident. To document media dissemination we searchedLexis-Nexis for news stories mentioning “Richardson.”

Results: In the 2 weeks prior to March 16, 2009, the census-adjusted rate was 0.81% (95% CI0.54–1.16) and there were no stories. The first media reports appeared on March 16, 2009, (n = 19)and quickly doubled (n = 40, n = 43) over the subsequent 2 days. The rate of CTs nearly doubledduring the 2 weeks post accident 1.46% (1.10–1.91%). This absolute increase in rate percentagewas statistically significant. (0.65%; 0.17 to 1.14%).

Conclusion: The percentage of all ED patients seen with mild trauma tested with head CT almostdoubled when comparing the pre-Richardson accident vs. post time periods. There was an increasein media reports of the accident that occurred rapidly after the event and peaked on day 3. [West J Emerg Med. 2012;13(6):548-550]