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

Human trafficking continues to persist, affecting up to 200 million people worldwide. As clinicians in emergency departments commonly encounter victims of intimate partner violence, some of these encounters will be with trafficking victims. These encounters provide a rare opportunity for healthcare providers to intervene and help. This case report of a human trafficking patient from a teaching hospital illustrates the complexity in identifying these victims. Clinicians can better identify potential trafficking cases by increasing their awareness of this phenomenon, using qualified interpreters, isolating potential victims by providing privacy and using simple clear reassuring statements ensuring security. A multidisciplinary approach can then be mobilized to help these patients. [West J Emerg Med. 2010;11(5); 402-404.]

West J Emerg Med. 2010; 11(5):405-407.

Objective: Persons with chronic or recurrent pain frequently visit the emergency department (ED), yet little research examines this experience. We conducted this national survey to assess patients’ ED experiences.

Methods: We developed and conducted a ten-minute telephone survey using random digit dial methodology. We included adults with chronic or recurrent pain reporting an ED visit within two years.

Results: We interviewed 500 adults. Sixty percent were female, their median age was 54, two-thirds were under a physician’s care, and 14% were uninsured. They reported an average of 4.2 ED visits within the past two years. Almost one-half reported “complete” or “a great deal” of pain relief during the ED visit, while 78% endorsed as “somewhat or definitely true” that “the ED staff understood how to treat my pain.” Although over three-fourths of patients felt that receiving additional information on pain management or referrals to specialists was “extremely” or “very” important, only one-half reported receiving such referrals or information. A significant minority (11%) reported that the “ED staff made me feel like I was just seeking drugs.” The majority (76%) were “somewhat” to “completely satisfied” with their treatment while 24% were "neutral" to “completely dissatisfied”. In multivariate models, age, recurrent pain, waiting time, imaging, receiving analgesics and pain relief predicted patient satisfaction.

Conclusion: Although those with chronic or recurrent pain report relatively high satisfaction with the ED, our findings suggests that specific areas, such as unmet needs for information and specialty referral, might be targeted to improve care. [West J Emerg Med. 2010; 11(5): 408-415.]

Out-of-hospital emergencies occur frequently, and laypersons are often the first to respond to these events. As an outreach to our local communities, we developed “Basic Emergency Interventions Everyone Should Know,” a three-hour program addressing cardiopulmonary resuscitation and automated external defibrillator use, heart attack and stroke recognition and intervention, choking and bleeding interventions and infant and child safety. Each session lasted 45 minutes and was facilitated by volunteers from the emergency department staff. A self-administered 13-item questionnaire was completed by each participant before and after the program. A total of 183 participants completed the training and questionnaires. Average score pre-training was nine while the average score post-training was 12 out of a possible 13 (P< .0001). At the conclusion of the program 97% of participants felt the training was very valuable and 100% would recommend the program to other members of their community. [West J Emerg Med. 2010;11(5):416-418.]

Objective: To determine the prevalence of diabetes in Southern California emergency department (ED) patients and describe the self-reported general health, demographic and social characteristics of these patients with diabetes. Methods: Between April 2008 and August 2008, non-critical patients at two Southern California EDs completed a 57-question survey about their chronic medical conditions, general health, social and demographic characteristics. Results: 11.3% of the 1,303 patients surveyed had diabetes. Patients with diabetes were similar to ED patients without diabetes with respect to gender, ethnicity and race. However, patients with diabetes were older (51 vs. 41), less likely to have a high school education (64.0% vs. 84.7%), less likely to speak English (44.9% vs. 55.4%), and less likely to be uninsured (33.3% vs. 49.5%). Additionally, patients with diabetes had markedly lower self-reported physical health scores (37.1 vs. 45.8) and mental component score and mental health scores (42.0 vs. 47.4) compared with ED patients without diabetes. Conclusion: In this study of two Southern California EDs, 11.3% of surveyed patients had diabetes. These patients were often poorly educated, possessed limited English language skills and poor physical health. ED personnel and diabetes educators should be mindful of these findings when designing interventions for ED patients with diabetes. [West J Emerg Med. 2010; 11(5):419-422.]

Objective: GlideScope® videolaryngoscopy (GVL) has been shown to improve visualization of the glottis compared to direct laryngoscopy (DL). However, due to the angle of approach to the glottis, intubation can still be challenging. We hypothesized that novice GVL users would be able to intubate faster and easier using an airway introducer (frequently known as a bougie) than with a standard intubating stylet. Methods: Intubations were performed on a human airway simulator with settings for easy and difficult airways. Participants were emergency medicine (EM) residents or faculty (n=21) who were novice GVL users. Participants were intubated a total of eight times (four GVL, four DL) using either a bougie or an intubating stylet. We recorded time to intubate (TTI) and difficulty rating using a visual analog scale (VAS) and non-parametric statistical methods for analysis. We reported medians with interquartile range (IQR). Results: The median TTI with difficult airway settings and the bougie-GVL was 76 seconds (IQR 50, 102) versus 64 seconds (IQR 50.5, 125), p=0.76 for the stylet-GVL combination. The median VAS difficulty score, on difficult airway settings, for the bougie-GVL was 5 cm (IQR 3.3, 8.0) versus 6.2cm (IQR 5.0, 7.5) with the stylet-GVL, p=0.53. Conclusion: Among novices using GVL for simulated difficult airway management, there was no benefit, in terms of speed or ease of intubation, by using the bougie over the standard stylet. [West J Emerg Med. 2010; 11(5):426-431.]

Objective: The aim of this study was to determine the rate of infection at which it is cost-effective to treat dog bite wounds with antibiotics.

Methods: Our study was composed of two parts. First we performed a randomized, doubleblind controlled trial (RCT) to compare the infection rates of dog bite wounds in patients given amoxicillin-clavulanic acid versus placebo. Subjects were immunocompetent patients presenting to the emergency department (ED) with dog bite wounds less than 12 hours old without suspected neurovascular, tendon, joint or bone injury, and who had structured follow-up after two weeks. Second, we developed a cost model with sensitivity analysis to determine thresholds for treatment.

Results: In the RCT, primary outcomes were obtained in 94 patients with dog bites. The overall wound infection rate at two weeks was 2% [95% CI 0 to 7%]. Two of 46 patients (4%) receiving no antibiotics developed infections, while none of the 48 patients (0%) receiving prophylactic antibiotics developed an infection (absolute reduction 4% [95% CI -1.0 to 4.5%]). Using a sensitivity analysis across a rate of infections from 0-10%, our cost model determined that prophylactic antibiotics were cost effective if the risk of wound infection was greater than 5% and antibiotics could decrease that risk by greater than 3%.

Conclusion: Our wound infection rate was lower than older studies and more in line with current estimates. Assuming that prophylactic antibiotics could provide an absolute risk reduction (ARR) of 3%, it would not be cost effective to treat wounds with an infection rate of less than 3% and unlikely that the ARR would be achievable unless the baseline rate was greater than 5%, suggesting that only wounds with greater than 5% risk of infection should be treated. Future work should focus on identifying wounds at high-risk of infection that would benefit from antibiotic prophylaxis. [West J Emerg Med. 2010; 11(5):435-441.]

Objective: To describe the characteristics of wrestling injuries occurring in male athletes aged 7-17 treated in United States (U.S.) emergency departments (ED) from 2000-2006, and to compare injury patterns between younger & older youth wrestlers.

Methods: A stratified probability sample of U.S. hospitals providing emergency services in the National Electronic Injury Surveillance System was used for 2000-2006. ED visits for injuries sustained in organized wrestling were analyzed for male patients ages 7-17 years old (subdivided into 7-11 years old [youth group] and 12-17 years old [scholastic group]).

Results: During the study period, there were an estimated 167,606 ED visits for wrestling injuries in 7-17 years old U.S. males, with 152,710 (91.1%) occurring in the older (12-17 years old) group. The annual injury incidence was 6.49 injuries/1,000 wrestlers in the youth group and 29.57 injuries/1,000 wrestlers in the scholastic group. The distribution of diagnoses was similar in both age groups, with sprain/strain as the most common diagnosis, followed by fracture and contusion/abrasion. Distributions of injury by location were significantly different between groups (p=0.02), although both groups exhibited approximately 75% of all injuries from the waist up. Overexertion and struck by/against were the most common precipitating and direct mechanisms in both groups, respectively. Over 97% of all injured wrestlers were treated and released.

Conclusion: The types of injury in youth (7-11 years old) wrestlers are similar to those of scholastic (12-17 years old) wrestlers, although the distribution of body parts injured differs between the age groups. The majority of injuries occurs above the waist and may be a target for prevention strategies. [West J Emerg Med. 2010; 11(5):442-449.]

Objective: To test the diagnostic use of the triage white blood cell (WBC) count in differentiating major from minor injuries.

Methods: We conducted a retrospective study of a prospectively collected database of trauma patients 13 years of age or older at a Level I trauma center from January 2005 through December 2008. We excluded all patients with obvious life-threatening injuries requiring immediate surgery, isolated head trauma, transferred from another institution or dead on arrival. We recorded age, sex, injury mechanism, vital signs, WBC, base deficit (BD), lactate (LAC) and calculated injury severity scores (ISS). Major injury was defined as either a change in hematocrit >10 points or blood transfused within 24 hours, or ISS >15.

Results: 805 patients were included in the study with an average age of 38.6 years (Range 13-95 yrs) years. 75.3% of patients were male, 45.6% had blunt and 34.4% had penetrating trauma. For vital signs, blood pressure was not significantly different between major and minor injury patients. Major compared to minor injury patients had a statistically but not clinically significant higher heart rate. Major injury patients had significantly (p < 0.0001) higher WBC count (10.53 K/µl, 95% CI: 9.7-11.3) compared to patients with minor injuries (8.92 K/µl, 95% CI: 8.7-9.2), but both were in the normal range. Patients with major compared to minor injury had significantly (p < 0.0001) higher BD (-3.1 versus -0.027 mmol/L) and higher LAC (3.9 versus 2.48 mmol/L). Areas under the curve for WBC count (0.60, 95% CI: 0.54-0.66) are similar to BD (0.69, 95% CI: 0.63-0.74) and LAC (0.66, 95% CI: 0.60-0.71).

Conclusion: WBC count is not a useful addition as a diagnostic indicator of major trauma in our study population. [West J Emerg Med. 2010; 11(5):450-455.]

The identification and appropriate management of those at highest risk for life-threatening anaphylaxis remains a clinical enigma. The most widely used criteria for such patients were developed in a symposium convened by National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network. In this paper we review the current literature on the diagnosis of acute allergic reactions as well as atypical presentations that clinicians should recognize. Review of case series reveals significant variability in definition and approach to this common and potentially life-threatening condition. Series on fatal cases of anaphylaxis indicate that mucocutaneous signs and symptoms occur less frequently than in milder cases. Of biomarkers studied to aid in the work-up of possible anaphylaxis, drawing blood during the initial six hours of an acute reaction for analysis of serum tryptase has been recommended in atypical cases. This can provide valuable information when a definitive diagnosis cannot be made by history and physical exam. [West J Emerg Med. 2010; 11(5); 456-461.]

[West J Emerg Med. 2010; 11(5):462.]

In preparing a case report on Brown-Séquard syndrome for publication, we made the incidental finding that the inexpensive, commercially available three-dimensional (3D) rendering software we were using could produce high quality 3D spinal cord reconstructions from any series of two-dimensional (2D) computed tomography (CT) images. This finding raises the possibility that spinal cord imaging capabilities can be expanded where bundled 2D multi-planar reformats and 3D reconstruction software for CT are not available and in situations where magnetic resonance imaging (MRI) is either not available or appropriate (e.g. metallic implants). Given the worldwide burden of trauma and considering the limited availability of MRI and advanced generation CT scanners, we propose an alternative, potentially useful approach to imaging spinal cord that might be useful in areas where technical capabilities and support are limited. [West J Emerg Med. 2010; 11(5):463-466.]

Purpose: The purpose of this study is to evaluate the needs of internal medicine residents rotating through the emergency department (ED).

Methods: A survey was distributed to 100 internal medicine residents (post-graduate years 2 and 3) from two different residency programs before the start of their emergency medicine (EM) rotation. Residents ranked the level of importance and the level of preparedness for 23 different EM topics, using a Likert-type scale ranging from 1 (least important/least prepared) to 4 (most important/most prepared). We calculated delta values (Δ) from the difference between importance and preparedness and undertook significance testing of this difference.

Results: A total of 71 out of 100 surveys were completed properly and returned. Internal medicine residents felt most ill-prepared in the areas of orthopedics, environmental emergencies, otolaryngology, airway management, and ophthalmology. The largest perceived gaps between importance and preparedness lay within the areas of airway management ( Δ=1.30), ophthalmology ( Δ=1.10), environmental emergencies (Δ=0.96), and orthopedics ( Δ=0.96).

Conclusion: Our data suggest that internal medicine residents are inadequately prepared for EM topics that they feel are important to their education, specifically airway management, ophthalmology, environmental emergencies and orthopedics. It is quite possible that other specialty residents are also poorly prepared for similar core EM topics. These data will hopefully guide future curricular change for off-service residents in the ED. [West J Emerg Med. 2010;11(5):470-473.]

Objective: We sought to characterize the experiences and preferences of applicants to emergency medicine (EM) residency programs about being contacted by programs after their interview day but before the rank list submission deadline.

Methods: This cross-sectional study surveyed all applicants to an academic EM residency during the 2006-2007 interview cycle. Participation was anonymous and voluntary. We used a Web-based survey software program to administer the survey in February 2007, after rank lists were submitted. Two additional invitations to participate were sent over the next month. The instrument contained multiple-choice and free-text items. This study was submitted to our Institutional Review Board and was exempt from formal review.

Results: 240/706 (34%) of applicants completed the survey. 89% (214/240) of respondents reported being contacted by a residency program after their interview but before rank lists were due. Of those contacted, 91% report being contacted by e-mail; 67% by mail; and 55% by phone. 51% of subjects reported that being contacted changed the order of their rank list in at least one case. A majority of contacted applicants felt “happy” (58%) or “excited” (56%) about being contacted, but significant numbers reported feeling “put on the spot” (21%) or “uncomfortable” (17%). A majority felt that it is appropriate for programs to contact applicants after interview day but before the rank lists are submitted, but 39% of contacted subjects responded that contact by phone is either “always inappropriate” or “usually inappropriate.” Regarding perceptions regarding the rules of the match, 80% (165/206) of respondents felt it was appropriate to tell programs where they would be ranked, and 41% (85/206) felt it was appropriate for programs to notify applicants of their place on the program’s rank list.

Conclusion: Most EM residency applicants report being contacted by programs after the interview day but before rank lists are submitted. Although applicants feel this practice is appropriate in general, over a third of subjects feel that contact by phone is inappropriate. These findings suggest that residency programs can expect a majority of their applicants to be contacted after an interview at another program, and shed light on how applicants perceive this practice. [West J Emerg Med. 2010; 11(5):474-478.]

Objective: To assess academic emergency medicine (EM) chairs’ perceptions of quality improvement (QI) training programs.

Methods: A voluntary anonymous 20 item survey was distributed to a sample of academic chairs of EM through the Association of Academic Chairs of Emergency Medicine. Data was collected to assess the percentage of academic emergency physicians who had received QI training, the type of training they received, their perception of the impact of this training on behavior, practice and outcomes, and any perceived barriers to implementing QI programs in the emergency department.

Results: The response rate to the survey was 69% (N = 59). 59.3% of respondents report that their hospital has a formal QI program for physicians. Chairs received training in a variety of QI programs. The type of QI program used by respondents was perceived as having no impact on goals achieved by QI (χ2 = 12.382; p = 0.260), but there was a statistically significant (χ2 = 14.383; p = 0.006) relationship between whether or not goals were achieved and academic EM chairs’ perceptions about return on investment for QI training. Only 22% of chairs responded that they have already made changes as a result of the QI training. 78.8% of EM chairs responded that quality programs could have a significant positive impact on their practice and the healthcare industry. Chairs perceived that QI programs had the most potential value in the areas of understanding and reducing medical errors and improving patient flow and throughput. Other areas of potential value of QI include improving specific clinical indicators and standardizing physician care.

Conclusion: Academic EM chairs perceived that QI programs were an effective way to drive needed improvements. The results suggest that there is a high level of interest in QI but a low level of adoption of training and implementation.[West J Emerg Med. 2010; 11(5):479-485.]

Introduction: Faculty often evaluate learners in the emergency department (ED) at the end of each shift. In contrast, learners usually evaluate faculty only at the end of a rotation. In December 2007 [X] School of Medicine changed its evaluation process, requiring ED trainees to complete end-of-shift evaluations of faculty.

Objective: Determine the feasibility and acceptance of end-of-shift evaluations for emergency medicine faculty.

Methods: We conducted this one-year observational study at two hospitals with 120,000 combined annual ED visits. Trainees (residents and students) anonymously completed seven-item shift evaluations and placed them in a locked box. Trainees and faculty completed a survey about the new process.

Results: During the study, trainees were assigned 699 shifts, and 633 end-of-shift evaluations were collected for a completion rate of 91%. The median number of ratings per faculty was 31, and the median number of comments was 11 for each faculty. The survey was completed by 16/22 (73%) faculty and 41/69 (59%) trainees. A majority of faculty (86%) and trainees (76%) felt comfortable being evaluated at end-of-shift. No trainees felt it was a time burden.

Conclusion: Evaluating faculty following an ED shift is feasible. End-of-shift faculty evaluations are accepted by trainees and faculty. [West J Emerg Med. 2010; 11(5):486-490.]

Objective: The Education in Palliative and End-of-life Care for Emergency Medicine Project (EPEC™-EM) is a comprehensive curriculum in palliative and end-of-life care for emergency providers. We assessed the adaptation of this course to an EM residency program using synchronous and asynchronous learning.

Methods: Curriculum adaptation followed Kern’s standardized six-step curriculum design process. Post-graduate year (PGY) 1-4 residents were taught all EPEC™-EM cognitive domains, divided as seven synchronous and seven asynchronous modules. All synchronous modules featured large group didactic lectures and review of EPEC™-EM course materials. Asynchronous modules use only EPEC™-EM electronic course media for resident self-study. Targeted evaluation for EPEC™-EM knowledge objectives was conducted by a prospective case-control crossover study, with synchronous learning serving as the quasi-control, using validated exam tools. We compared de-identified test scores for effectiveness of learning method, using aggregate group performance means for each learning strategy.

Results: Of 45 eligible residents 55% participated in a pre-test for local needs analysis, and 78% completed a post-test to measure teaching method effect. Post-test scores improved across all EPEC™-EM domains, with a mean improvement for synchronous modules of +28% (SD=9) and a mean improvement for asynchronous modules of +30% (SD=18). The aggregate mean difference between learning methods was 1.9% (95% CI -15.3, +19.0). Mean test scores of the residents who completed the post-test were: synchronous modules 77% (SD=12); asynchronous modules 83% (SD=13); all modules 80% (SD=12).

Conclusion: EPEC™-EM adapted materials can improve resident knowledge of palliative medicine domains, as assessed through validated testing of course objectives. Synchronous and asynchronous learning methods appear to result in similar knowledge transfer, feasibly allowing some course content to be effectively delivered outside of large group lectures. [West J Emerg Med. 2010; 11(5):491-498.]

Objective: To use 360-degree evaluations within an Observed Structured Clinical Examination (OSCE) to assess medical student comfort level and communication skills with intimate partner violence (IPV) patients.

Methods: We assessed a cohort of fourth year medical students’ performance using an IPV standardized patient (SP) encounter in an OSCE. Blinded pre- and post-tests determined the students’ knowledge and comfort level with core IPV assessment. Students, SPs and investigators completed a 360-degree evaluation that focused on each student’s communication and competency skills. We computed frequencies, means and correlations.

Results: Forty-one students participated in the SP exercise during three separate evaluation periods. Results noted insignificant increase in students’ comfort level pre-test (2.7) and post-test (2.9). Although 88% of students screened for IPV and 98% asked about the injury, only 39% asked about verbal abuse, 17% asked if the patient had a safety plan, and 13% communicated to the patient that IPV is illegal. Using Likert scoring on the competency and overall evaluation (1, very poor and 5, very good), the mean score for each evaluator was 4.1 (competency) and 3.7 (overall). The correlations between trainee comfort level and the specific competencies of patient care, communication skill and professionalism were positive and significant (p<0.05).

Conclusion: Students felt somewhat comfortable caring for patients with IPV. OSCEs with SPs can be used to assess student competencies in caring for patients with IPV. [West J Emerg Med. 2010; 11(5):500-505.]

Emergency physicians (EP) and medical toxicologists are integral in identifying and treating patients with overdoses. Transplant centers are expanding acceptance criteria to consider those with poison-related deaths. We present a case of a simultaneous gunshot wound to the head and an acetaminophen overdose. This case highlights the importance of EPs and medical toxicologists in recognizing the medical complexity of suicides, optimizing treatment, and timing of organ procurement. Early antidote administration and aggressive supportive care allowed the patient to be evaluated as a potential donor. EPs and medical toxicologists have integral roles in overdose patients as organ donors. [West J Emerg Med. 2010; 11(5):506-509.]

Background: Seizure as the initial manifestation of aortic dissection is rare.

Case report: An 88-year-old female experienced a first generalized tonic clonic seizure, which was terminated with midazolam. Acute cerebral magnetic resonance imaging and angiography were non-informative. After awaking she complained about cramping pain in the right upper extremity, which was accompanied by involuntary flexion movements of the right upper extremity. Blood pressure was initially normal. Blood gases revealed metabolic acidosis and blood chemical investigations a markedly increased D-dimer. Consecutively blood pressure declined and transthoracic echocardiography showed pericardial effusion. A computed tomography scan of the thorax revealed an aortic dissection type A. The patient died 16 hours after admission after cardiothoracic surgeons had refused surgical treatment.

Conclusion: This case shows that a generalized tonic-clonic seizure may be the initial manifestation of an aortic dissection type A in the absence of thoracic chest pain and that brachyalgia may not develop earlier than with progression of the dissection. [West J Emerg Med. 2010; 11(5):510-511.]

We report a case of iatrogenic claudication as a result of a misplaced percutaneous arterial closure device (PACD) used to obtain hemostasis after cardiac catheterization. The patient presented one week after his procedure with complaints suggestive of right lower extremity claudication. Computed tomographic angiography demonstrated a near total occlusion of the right common femoral artery from a PACD implemented during the cardiac catheterization. The use of PACD’s to obtain rapid hemostasis is estimated to occur in half of all cardiac catheterizations. Ischemic complications as a result of these devices must be considered when evaluating post procedural patients with extremity complaints. [West J Emerg Med. 2010; 11(5):512-513.]

West J Emerg Med. 2010; 11(5):516-517.

West J Emerg Med. 2010;11(5):518-519.

Latrodectus envenomations are common throughout the United States and the world. While many envenomations can result in catecholamine release with resultant hypertension and tachycardia, myocarditis is very rare. We describe a case of a 22- year-old male who sustained a Latrodectus envenomation complicated by cardiomyopathy. [West J Emerg Med. 2010; 11(5):521-523.]

Rodenticides have historically been common agents in attempted suicides. As most rodenticides in the United States (U.S.) are superwarfarins, these ingestions are generally managed conservatively with close monitoring for coagulopathy, and if necessary, correction of any resulting coagulopathy. However, alternate forms of rodenticides are imported illegally into the U.S. and may be ingested either accidentally or in suicide attempts. We present an unusual case of poisoning by the illegally imported rodenticide, “Tres Pasitos.” The main ingredient of this rat poison is aldicarb, a potent carbamate pesticide that causes fulminant cholinergic crisis. This case is relevant and timely because carbamates and organophosphates are still used as insecticides and emergency physicians (EP) working in rural areas may have to evaluate and manage patients with these poisonings. As international travel and immigration have increased, so has the possibility of encountering patients who have ingested toxic substances from other countries. In addition, there has been increased concern about the possibility of acts of terrorism using chemical substances that cause cholinergic toxidromes. , EPs must be able to recognize and manage these poisonings. This report describes the mechanism of action, clinical manifestations, laboratory evaluation and management of this type of poisoning. The pertinent medical literature on poisoning with aldicarb and similar substances is reviewed. [West J Emerg Med. 2010; 11(5):524-527.]

Ultrasound images of a patient presenting to the Emergency Department with expressive aphasia who was found to have carotid dissection. The first image is a standard 2D image that depicts the internal carotid with a visible flap within the lumen. The second image is a color Doppler image showing turbulent flow within the true lumen and visible flow within the false lumen. The case and the patient’s outcome are summarized along with some teaching points about carotid dissection. Also, there is some background and research on using ultrasound to help identify dissection. [West J Emerg Med. 2010;11(5):530-531.]