Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Study Objective: To determine the ability of emergency department (ED) physicians to diagnose cholelithiasis with bedside ultrasound. Methods: ED gallbladder ultrasounds recorded over 37 months were compared to radiology ultrasound interpretation. Results: Of 1,690 ED gallbladder ultrasound scans performed during this period, radiology ultrasound was performed in 575/1690 (34%) cases. ED physician bedside interpretation was 88% sensitive [95% CI, 84-91] and 87% specific [95% CI, 82-91], while positive predictive value (PPV) was 91% [88- 94%] and negative predictive value (NPV) was 83% [78-87%], using radiology interpretation as the criterion reference. Conclusion: ED physician ultrasound of the gallbladder for cholelithiasis is both sensitive and specific.

Study Objective: To determine the accuracy of the online Social Security Death Index (SSDI) for determining death outcomes. Methods: We selected 30 patients who were determined to be dead and 90 patients thought to be alive after an ED visit as determined by a web-based searched of the SSDI. For those thought to be dead we requested death certificates. We then had a research coordinator blinded to the results of the SSDI search, complete direct follow-up by contacting the patients, family or primary care physicians to determine vital status. To determine the sensitivity and specificity of the SSDI for death at six months in this cohort, we used direct follow-up as the criterion reference and calculated 95% confidence intervals. Results: Direct follow-up was completed for 90% (108 of 120) of the patients. For those patients 20 were determined to be dead and 88 alive. The dead were more likely to be male (57%) and older [(mean age 83.9 (95% CI 79.1 – 88.7) vs. 60.9 (95% CI 56.4 – 65.4) for those alive]. The sensitivity of the SSDI for those with completed direct follow-up was 100% (95% CI 91 -100%) with specificity of 100% (95% CI 98-100%). Of the 12 patients who were not able to be contacted through direct follow-up, the SSDI indicated that 10 were dead and two were alive. Conclusions: SSDI is an accurate measure of death outcomes and appears to have the advantage of finding deaths among patients lost to follow-up.

Background: Lumbar Puncture (LP) is an invasive procedure frequently used to diagnose meningitis among the pediatric population. Neonates and infants have not routinely received local anesthesia prior to LP. Study Objective: To determine whether emergency medicine physicians and pediatricians use local analgesics on neonates and infants prior to performing an LP and to identify which local anesthetics, if any, were used. Methods: Prospective, cohort study of all infants, six months of age or less, that received an LP in the emergency department (ED) or inpatient pediatric units for suspected meningitis during a period of year at a university tertiary care hospital. Results: A total sample population of 111 infants that received an LP within the study period. A control population of 42 adults received an LP. Only 40.4% (45/111) of the infants received local analgesia prior to LP: either 1% lidocaine, EMLA or a combination of the two. Infants were less likely to receive lidocaine or EMLA prior to LP compared to adult subjects (OR= 0.27; 95% CI0.12 to 0.62). No neonates that were less than one month of age received local procedural anesthesia by emergency medicine or pediatric physicians. ED physicians’ use of local anesthesia prior to LP increased with increasing age of the infant. The pediatricians in this study used local anesthesia prior to LP when the infant was at least five months of age. Discussion: The data objectively support recent literature regarding the under use or lack of use of analgesia prior to LP among neonates and infants. Local anesthetics should be used routinely without exception prior to performing an LP in the pediatric population.

Prediction models using multiple logistic regression are appearing with increasing frequency in the medical literature. Problems associated with these models include the complexity of computations when applied in their pure form, and lack of availability at the bedside. Personal digital assistant (PDA) hand-held devices equipped with spreadsheet software offer the clinician a readily available and easily applied means of applying predictive models at the bedside. The purposes of this article are to briefly review regression as a means of creating predictive models and to describe a method of choosing and adapting logistic regression models to emergency department (ED) clinical practice.

A 19-year-old female with Systemic Lupus Erythematosus (SLE) presented with ischemia of her left hand following trauma. Medical therapy was initiated but failed to improve her symptoms, and revision amputation was ultimately performed. The patient’s final diagnosis was digital ischemia due to secondary Raynaud’s Phenomenon (RP). The authors discuss diagnosis, complications, and treatment of this relatively uncommon disorder. The authors report this case in order to discuss how secondary RP can be complicated by ischemia and the multidisciplinary approach that needs to take place to prevent the latter from occurring.