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

Introduction: Spectral Doppler echocardiography is used to evaluate diastolic dysfunction of the heart. However, it is difficult to assess diastolic function with this modality in emergency department (ED) settings. Based on the hypothesis that E-point septal separation (EPSS) measured by M-mode in the parasternal long-axis (PSLA) view may facilitate the assessment of diastolic function in emergency patient care, we aimed to investigate whether EPSS measured by M-mode in the PSLA view correlates with spectral Doppler assessment in patients with grade 1 diastolic dysfunction.

Methods: We performed this prospective, observational, single-center study was performed in the ED of a tertiary training and research hospital. All patients who presented to the emergency critical care unit with symptoms of heart failure were evaluated by the cardiology department, had grade 1 diastolic dysfunction confirmed by the cardiology department, and did not meet any of the study’s exclusion criteria. The study population of 40 (included rate 14%) was formed after the exclusion criteria were applied to 285 patients who met these conditions. Patients included in the study underwent spectral Doppler measurements in the apical four-chamber (A4C) view followed by M-mode measurements in the PSLA view. We then compared the measurements.

Results: The correlation between the early diastolic velocity of the mitral inflow to the late diastolic velocity (E/A) ratio in spectral Doppler measurements and the EPSS/ A-point septal separation (APSS) ratio in M-mode was strong (correlation coefficient 0.677, P = 0.001). Similarly, the correlation between E in spectral Doppler measurements and the EPSS/APSS ratio in M-mode measurements was also moderately strong (correlation coefficient 0.557, P = 0.001).

Conclusion: A significant correlation exists between the M-mode EPSS/APSS ratio measurement in the PSLA view and the spectral Doppler E/A ratio measurement in the A4C window to evaluate grade 1 diastolic dysfunction. This association suggests that M-mode measurements in the PSLA may be used in diastolic dysfunction.

Introduction: The choice of medications used in rapid sequence intubation (RSI) can result in the difference between an acceptable outcome and a lethal one. When executed properly, RSI is a lifesaving intervention. Nonetheless, RSI may result in fatal complications such as peri-intubation cardiac arrest. The risk of peri-intubation cardiac arrest reportedly increases in patients who are profoundly hypoxic or hypotensive prior to endotracheal intubation. Medication choice for RSI may either optimize or deoptimize hemodynamic parameters, thereby impacting patient outcomes. Therefore, our study aimed to examine the association of change in mean arterial pressure (MAP) with and without the use of a predetermined dose of 50 micrograms (μg) intravenous fentanyl as a pretreatment agent during RSI.

Methods: This prospective observational study included patients undergoing RSI at an academic emergency department (ED) over a three-year period between January 1, 2018–January 1, 2021. Average hemodynamic parameters were measured at the time of induction (prior to medication administration) and 10 minutes after induction. We categorized patients into fentanyl and non-fentanyl groups for analysis, and we compared data using chi-square and t-test as appropriate. Logistic regression analysis was conducted to account for potential confounding factors.

Results: A total of 278 patients were included in the analysis, of whom 160 received fentanyl and 118 did not. The majority of the patients underwent RSI by trainees 95.0% of the time. The first-pass success rate was 77.7% in our sample and did not differ significantly between the two groups (P = 0.84). Unadjusted analysis showed a larger decrease in hemodynamic parameters in the fentanyl group compared to the non-fentanyl group; systolic blood pressure decreased by 11.2% vs 1.6%, diastolic blood pressure decreased by 13.7% vs 3.8%, and MAP decreased by 12.7% vs 3.2%. After adjusting for potential confounders, fentanyl was 2.14 times more likely to lower MAP by 10%.

Conclusion: The use of 50 μg fentanyl for rapid sequence intubation in an ED is associated with higher odds of decreasing mean arterial pressure by at least 10% at 10 minutes from the time of induction. Therefore, it should be carefully dosed, and its use in clinical practice should be justified to avoid unnecessary complications.

Introduction: Emergency departments (ED) play a central role in defining the effectiveness and quality of the overall hospital’s mass casualty incident (MCI) response. The use of electronic health records (EHR) in hospital settings has been rapidly growing globally. There is, however, a paucity of literature on the use and performance of EHR during MCIs.

Methods: In this study we aimed to describe EHR use, as well as the challenges and lessons learnt in response to the 2020 explosion in the Port of Beirut, Lebanon, during which the hospital received over 360 casualties.

Results: Information technology support, reducing EHR system restrictions, cross-function training, focus on registration and patient identification, patient flow and tracking, mobility and bedside access, and alternate sites of care are all important areas to focus on during emergency/disaster response planning.

Conclusion: Innovative solutions that help address logistical challenges for different aspects of the disaster response are needed.

Background: Disastrous situations in the emergency department (ED) or community can overwhelm even the best-prepared teams due to their complexity and dynamic nature. In this paper we propose an integrated approach to disaster management, combining six theoretical and practical frameworks to enhance decision-making and operational effectiveness.

Discussion: The approach begins with “sensemaking,” an instinctive process that helps leaders quickly gain situational awareness, a crucial foundation for the recognition-primed decision process (RPD). RPD enables swift, experience-based decisions without exhaustive analysis, aligning them with the appropriate domain in the Cynefin framework to guide subsequent interventions. In chaotic situations, rapid action is necessary, and the edge-of-chaos theory guides leaders to balance order and chaos for optimal adaptability. Complexity theory aids in managing the unpredictable elements of a crisis, highlighting the need for flexible responses. Finally, the Incident Command System ensures effective implementation by providing a standardized approach to command, control,
and coordination. This cohesive strategy equips emergency physicians and incident commanders to manage both internal ED crises and broader community disasters effectively, with an emphasis on the importance of training in these frameworks to enhance the resilience of emergency medical services.

Conclusion: This multifaceted approach should improve disaster management by better preparing responders for the unpredictable nature of emergencies, enabling effective evaluation and management of complex scenarios, and leading to a more rapid restoration of order.

Rural regions face emergency medicine (EM) physician shortages. Most training programs are located in cities and lack rural clinical experiences, didactics, and mentorship to excite and prepare residents for rural EM practice. There is limited data on optimal training methods for preparing residents for rural practice. To address this need for rural EM training and workforce, we developed a rural EM curriculum. We began with a two-year case review from critical access emergency departments.  Rural EM skills were defined and taught using lectures, simulation cases, and clinical rotations. We obtained quantitative and qualitative feedback from the first ten residents participating in the curriculum. Qualitatively, 10/10 residents gained new skills and found these experiences valuable to their training and career choice, with 100% expressing interest in rural practice and 75% choosing a rural practice. Quantitatively, residents managed a greater variability in patient acuity and volume and performed a greater variety of procedures compared to their academic center rotations, all while gaining unique skills from the challenges of a rural environment. Focused rural emergency medicine clinical experience and didactic training during residency are a promising approach to bridge the gap between urban tertiary care training programs and rural emergency care needs.

Introduction: Rural communities continue to face a shortage of emergency physicians despite the growing number of emergency medicine (EM) residencies. In rural areas, emergency physicians tend to be older, male, and White, and are less likely to have completed EM residency training or have board certification. There is also currently a higher rate of rural physicians leaving clinical practice than in urban emergency departments (ED). In this cross-sectional study we sought to identify the work environments of graduates of a rural EM residency program, and the strengths and weaknesses of such a program.

Methods: We conducted a survey among 29 graduates of a community-based EM program to evaluate the effectiveness of a residency program in training physicians who will work in rural areas. The survey assessed the graduates’ perceptions of their level of preparedness, further training, and practice location after completing the program. Results are reported using descriptive statistics.

Results: Twenty respondents completed the survey (69%). Most of them identified as male (60%), White (70%), and non-Hispanic or -Latino (80%). Seventy-five percent of the graduates work in counties with fewer than 1,000,000 inhabitants, and 70% work in community hospitals and EDs caring for fewer than 100,000 patients/year. Four (20%) declared to work in critical access hospitals. Overall, respondents felt confident in their residency training.

Conclusion: A community-based EM training program may be an effective strategy for producing emergency physicians who go on to work in rural and smaller communities.

Background: The Standardized Letter of Evaluation (SLOE) is a crucial component of the emergency medicine (EM) application process. Given the critical role of the SLOE, we attempted to better understand the grading scales used, as well as the distribution of grades and rank-list positions.
Objectives: Our primary objective in this study was to determine the distribution of grading formats, grades given, and rank-list positions across EM clerkships using the SLOE.

Methods: We performed a cross-sectional study of the grading formats, grades given, and ranking distributions as reported on the SLOE during the 2022–23 application cycle. We obtained data on SLOEs from EM residency programs accredited by the Accreditation Council for Graduate Medical Education by reviewing all applicants who applied to either of two EM residency programs in geographically different regions. Trained abstractors recorded the following data: number of students rotating in the prior year; grading format used; and grade and rank distribution among students.

Results: We included 264 programs in our final analysis, after 13 programs met exclusion criteria. The majority of programs (72.2%) use an Honors/High Pass/Pass/Fail grading scheme. We determined the mean percent of each grade: Honors/A 27.6%; High Pass/B 31.1%; Pass/C 40.8%; Low Pass/D 0.2%; and Fail/F 0.3%. Finally, we determined the mean percent for each rank-list position: top 10% was 17.6%; top third 36.5%; mid third 34.1%; and low third 11.8%.

Conclusion: We determined the grading schemes and grade and rank-list distributions for EM programs during the 2022–2023 academic year. Most programs used a Honors/High Pass/Pass/Fail grading scheme, with the majority of students receiving Honors or High Pass, while 0.3% failed their rotation. Both grades and rank list demonstrated evidence of a skewed distribution toward higher grades and rank-list position.

Introduction: While many aspects of emergency medicine (EM) residency training are standardized among residents within a single residency program, there is no standard for the distribution of chief complaints (CC) that residents should see over the course of residency. This could result in substantial variability in each resident’s clinical exposure. Our objective in this study was to explore EM residents’ clinical exposure to CCs to determine whether substantial variation exists. If such variation exists, this could suggest the need for curricular reform to address gaps in resident clinical exposure during training.

Methods: This was a retrospective observational study of EM residents who graduated in the years 2016–2021 at a single, university-affiliated emergency department (ED) in the midwestern United States. All patient encounters where a CC was logged were included and categorized into 1 of 20 clinical domains based on the 2016 American Board of Emergency Medicine Model of Clinical Practice. We calculated descriptive statistics for the top 10 most encountered domains for comparison among residents.

Results: We included a total of 228,916 patient encounters from 69 residents in the analysis. Residents were involved in an average of 3,323 distinct patient encounters during the study period. The overall interquartile range for patient encounters was 523. The three CC domains with the broadest interquartile variation were abdominal and gastrointestinal disorders (116), musculoskeletal disorders (nontraumatic)(93), and traumatic disorders (86).

Conclusion: Within a single, three-year academic EM program, substantial variation existed among residents with regard to the variety of patient CCs seen during their residency training. 

Introduction: Emergency department boarding has escalated to a crisis, impacting patient care, hospital finances, and physician burnout, and contributing to error. No prior studies have examined the effects of boarding hours on resident productivity. If boarding reduces productivity, it may have negative educational impacts. We investigated the effect of boarding on resident productivity as measured by patients per hour and hypothesized that increased boarding leads to decreased productivity.

Methods: This was a retrospective study at a quaternary, urban, academic Level I trauma center from 2017–2021 with a three-year emergency medicine residency of 10–12 residents per year and annual volumes of 80,000–101,000. Boarding was defined as the time between an admission order and the patient leaving the ED. We created a multivariable mixed model with fixed covariates for year, month, day of week, resident experience, shift duration, total daily ED patients, and with residents as repeated measures. The effect of boarding was estimated after covarying out all other factors.

Results: All variables included in the model were significantly associated with changes in productivity. Resident experience has the largest effect such that for each month of residency experience, a resident adds 0.012 patients per hour (95% confidence interval [CI] 0.010–0.014). Isolating the effect of boarding demonstrated that for every additional 100 hours of boarding, a resident’s productivity decreased by 0.022 patients per hour (95% CI 0.016–0.028). In the study, the median daily boarding was 261 hours; if this were eliminated (assuming a resident completes 100 10-hour shifts annually), a resident could be expected to see 56.9 more patients per year (95% CI 40.7–73.1).

Conclusion: Hospital boarding significantly reduces resident productivity as measured by patients per hour. Further studies are warranted to determine the educational impact.

Introduction: The utility of the three-part bedside oculomotor exam HINTS (head impulse test, nystagmus, test of skew) in the hands of emergency physicians remains under debate despite being supported by the most recent literature. Educators historically lack consensus on how specifically to teach this skill to emergency medicine (EM) residents, and it is unknown whether and how EM residency programs have begun to implement HINTS training into their curricula. We aimed to characterize the state of HINTS education in EM residency and develop a needs assessment.

Methods: In this cross-sectional study, we administered a survey to EM residency directors, the themes of which centered around HINTS education perceptions, practices, resources, and needs. We analyzed Likert scales with means and 95% confidence intervals for normally distributed data, and with medians and interquartile ranges for non-normally distributed data. Frequency distributions, means, and standard deviations were used in all other analyses.

Results: Of 250 eligible participants, 201 (80.4%) responded and consented. Of the 192 respondents providing usable data, 149/191 (78.0%) believed the HINTS exam is valuable to teach; 124/192 (64.6%) reported HINTS educational offerings in conference; and 148/192 (77.1%) reported clinical bedside teaching by faculty. The most-effective educational modalities were clinical bedside teaching, online videos, and simulation. Subtopic teaching struggles with regard to HINTS were head impulse test and test-of-skew conduction and interpretation, selection of the correct patients, and overall HINTS interpretation. Teaching barriers centered around lack of faculty expertise, concern for poor HINTS reproducibility, and lack of resources. Leadership would dedicate a mean of 2.0 hours/year (SD 1.3 hours/year) to implementing a formal, standardized HINTS curriculum.

Conclusion: Despite controversy surrounding the utility of the HINTS exam in EM, most residency directors believe it is important to teach. This needs assessment can guide development of formal educational and simulation curricula focusing on residency directors’ cited HINTS exam educational struggles, barriers, and reported most-effective teaching modalities.

Introduction: The prolonged stay of critically ill patients in the emergency department (ED) may lead to worse clinical outcomes. An emergency department (ED)-based intensive care unit (ICU) is one of the proposed solutions to deliver critical care in the ED. We thus aimed to characterize existent ED-ICU models and their reported association with clinical outcomes in critically ill adult patients.

Methods: We searched the Ovid MEDLINE database from inception to October 2, 2023. We included studies that report an ED-ICU structure, defined as a space capable of providing ICU-level care within or adjacent to the ED, and its characteristics. We excluded personnel-focused intervention (without the presence of a separated space) or a space without ICU-level care capability. We collected information on process measures, patient-related outcomes, and cost-related outcomes.

Results: We screened 2,824 studies, of which 125 full-text articles were assessed for eligibility and 31 studies were included in this scoping review. Studies reported on 14 ED-ICUs across seven countries, with capacities ranging from 3–17 beds. All ED-ICUs served early and ongoing critical care needs in the ED, including three distinct themes: short-stay; palliative care; and disaster-response ICUs. Implementing the ED-ICU was associated with decreased time to ICU-level care and reduced number of inpatient ICU admissions, but it was not consistently associated with improved survival.

Conclusion: Several ED-ICUs have been established around the world with different characteristics depending on local needs. Implementation of the ED-ICU may be associated with improved clinical outcomes and patient flow.

Objective: Our goal was to assess emergency medical services (EMS) provider-perceived Alzheimer’s disease and related dementias (ADRD) by patient sociodemographic characteristics and ZIP code tabulation areas (ZCTA) in the prehospital setting.

Methods: We conducted a retrospective descriptive analysis of EMS calls with patient contact for adults ≥ 65 years of age who were provided prehospital care between February 1, 2020 and January 31, 2022, using data from the San Francisco Department of Emergency Management and the 2021 American Community Survey. Logistic regression models assessed the associated between EMS providerperceived ADRD and patient sociodemographic characteristics, including age, race/ethnicity, incident location, and ZCTA-level socioeconomic status.

Results: A total of 55,129 patient encounters were recorded, with EMS provider-perceived ADRD recorded in 4,112 (7.5%). Among cases with EMS provider-perceived ADRD, the most common primary impressions were mental disorders (17.1%), weakness (17.0%), injury (15.7%), and pain (13.1%). Increasing age was associated with higher odds of EMS provider-perceived ADRD among both sexes. Among females, EMS provider-perceived ADRD was higher among Hispanics (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11–1.52), Blacks (OR 1.20, 95% CI 1.03–1.40), Asians (OR 1.18, 95% CI 1.06–1.31), and Native Hawaiian and Pacific Islanders (OR 1.48, 95% CI 1.05–2.08]), while among males, only Asians (OR 87, 95% CI .76–.99) had lower odds, all compared to Whites. Females in lowand medium-income ZCTAs had lower odds of EMS provider-perceived ADRD relative to high-income ZCTAs, with no significant findings in males.

Conclusion: Our findings suggest a higher prevalence of EMS provider-perceived Alzheimer’s disease and related dementias among minoritized and socioeconomically disadvantaged populations, including the oldest adults, and racial and ethnic minority communities. Future research and more precise data collection is needed to ensure equity for older adults who access emergency care in the prehospital setting. 

Objective: This study determined if the caregivers of children in the emergency department (ED) have the same COVID-19 vaccination status as the child, the reasons they chose to not vaccinate the child, and self-identified barriers to vaccination to determine if the ED is appropriate for vaccination intervention.

Methods: A survey was administered to caregivers of pediatric ED patients at four Children’s Hospitals in: Augusta, GA, Buffalo, NY, Madison, WI, and Sacramento, CA. Participants were asked about their and the child’s demographics, vaccination status, and barriers to vaccination. We used descriptive statistics, Cohen's kappa, and logistic regression to analyze responses.

Results: 941 caregivers were considered for enrollment, and 800 consented to participation. Participants were 75% women with a mean age of 40.9 ± 8.9 years. 51% (409) of the pediatric ED patients were COVID-19 vaccinated, as were 74% (591) of the caregivers. There was variation across sites, but overall, 15% of caregivers of unvaccinated children wanted the child tobe vaccinated with the most common barriers to vaccination identified as safety data (25%), time availability (20%), and ability to obtain an appointment (13%). The most common reason for not wanting the child COVID-19 vaccinated was concern the vaccine didn’t work or had too many side effects.

Conclusion: A small but clinically important group of pediatric ED patients are not COVID-19 vaccinated but their caregivers want them to be vaccinated, indicating that consideration should be given to offering vaccination in the ED. Reasons for avoiding COVID-19 vaccination were primarily concerns with efficacy and side effects.

Background: In low- and middle-income countries (LMIC), 45% of deaths could be addressed by implementation of an emergency medical services (EMS) system. Prehospital care is a critical component of EMS worldwide, and basic, affordable training has been shown to improve EMS systems. However, patient outcome impact is unclear. In this study we aimed to assess the current state of prehospital care in Kigali, Rwanda, through a needs assessment, focused training intervention, and analysis of current practices and patient outcomes.

Methods: We identified 30 clinicians through the prehospital medical command office and included them in the study. A prospective, nonrandomized, interrupted time-series approach was used. Data collected through closed- and open-ended questionnaires included age, sex, training, and knowledge assessment. We used the data to create a tailored, 18-hour training after which immediate and 11-month post-tests were administered. Linked prehospital and hospital care datasets allowed for evaluation of patient outcomes and prehospital process indicators that included training skill application, airway intervention, intravenous fluid administration, and glucose administration.

Results: Of 30 clinicians, 18 (60%) were female, 19 were nurses, and 11 were nurse anaesthetists. Median age was 36, and median years providing care was 10 (IQR 7–11). Twenty-four (80%) participants completed immediate and post-test assessments. Mean knowledge across 12 core skills significantly improved from a pre-test mean of 59.7% (95% confidence interval [CI] 42.2–77.20) to a post-test mean of 87.8% (95% CI 74.7–100). At 11 months post-training, the score improvement maintained, with a mean score of 77.6%(95% CI 59.2–96.8). For patient outcomes, the total sample size was 572 patients; 324 of these patients were transported to the ED during the pre-training period (56.4%), while 248 were transported post-training. Prehospital oxygen administration for patients with a saturation level of <95% significantly increased pre- to post-training (66.7% to 71.7%; Δ = 5.0%; Δ95% CI 1.9,−8.1%). No significant changes were noted in patient treatment outcomes or other process indicators due to small sample sizes.

Conclusion: This study provides insights on Rwandan EMS and demonstrates that a tailored intervention targeting education on prehospital process indicators has positive impacts on clinician knowledge and practice.

Background: Diversity within the physician workforce is associated with improved clinical outcomes and patient satisfaction. Despite this, the US physician workforce, particularly in emergency medicine (EM), remains relatively homogeneous. Of all Black medical school students in the US, 14% attend the four Historically Black Colleges and Universities (HBCU) that have a medical school. Unfortunately, none of these schools are affiliated with an academic EM program. Because of this, there is less professional mentorship focused on obtaining a career in EM and potentially less formal curricula for senior medical students doing their home sub-internship in EM.

Objectives: Our objective was to fill the gap left by the absence of an academic EM department at Howard University College of Medicine (HUCOM) by creating a collaborative educational experience for fourth-year medical students during their home EM sub-internship. The curricular objectives were to teach core principles of EM, build relationships with students, and prepare them for pursuing EM residency training.

Curricular Design: Four EM academic departments collaborated to create and implement a virtual curriculum using the six-step approach to curricular development.

Impact/Effectiveness: After completion of the course, five students (100%) reported strongly agreeing with the following statements. These sessions 1) helped me learn the approach to core EM topics more than I would have been able to do on my own; 2) helped me learn key skills for excelling in an EM rotation more than I would have been able to do on my own; and 3) allowed me to connect with faculty and resident mentors to learn more about the field of EM. Of these five students, 80% and 20% reported strongly agreeing and agreeing, respectively, that these sessions helped them learn about the process of applying to and selecting an EM residency program.

Introduction: The emergency department (ED) is a safety net, caring for families who lack adequate access to food and other basic needs. The COVID-19 pandemic caused a dramatic rise in food insecurity (FI) nationally; however, little is known about the prevalence of FI among families seen in pediatric EDs (PED). In this study we aimed to determine the prevalence of FI, as well as awareness and utilization of supplemental food services, among families seen in an urban PED during the COVID-19 pandemic using an electronic screening survey.

Methods: This was a cross-sectional survey of families screened for FI in an urban PED. An electronic survey was advertised to all families via posters placed in patient rooms and other locations in the PED between February–October 2022. Surveys in English and Spanish were accessed on personal electronic devices via QR codes. Six validated US Department of Agriculture household food security questions and sociodemographic questions were included. We calculated respondents’ food security and performed descriptive and bivariate analyses of patient sociodemographics and responses to FI questions.

Results: Of 42,697 PED visits, 612 surveys were completed and analyzed (1.4%). Nearly 50% of respondents identified as White and non-Hispanic, with approximately 80% female. Thirty percent had a household income of <$25,000 and 32% between $25,000–<50,000. Among survey respondents, 56.7% demonstrated FI: 25% with low food security, and 31.7% with very low food security. We identified statistically significant differences in awareness and use of supplemental food services by FI status, household income, and primary language spoken.

Conclusions: Nearly 60% of survey participants in an urban pediatric ED during the COVID-19 pandemic experienced food insecurity, substantially higher than previous reports. These results support the ED’s contributory role in FI screening, particularly during times of a public health crisis, and highlights the need for targeted outreach in this setting.

Introduction: Providing appropriate healthcare for transgender, intersexual and non-binary (TIN) individuals remains a significant challenge, as this group experiences higher rates of health inequalities, discrimination, and barriers to accessing care. Emergency physicians (EP) often lack formal training and knowledge about caring for TIN patients, while comparatively less evidence is available for other healthcare professionals, including emergency nurses (EN). Therefore, our goal in this study was to explore the experiences, knowledge, and attitudes as well as education/training needs of both ENs and EPs in Germany regarding the care of TIN patients.

Methods: In February 2023, we electronically surveyed EPs and ENs from emergency departments (ED) across Germany. The survey, developed through literature review and collaboration with experts and members of the TIN community, consisted of 15 closed-ended items divided into three sections: experiences and knowledge; attitudes; and education/training needs. We used standard descriptive statistics and tested for group differences using the chi-square test.

Results: Of the approximately 1,665 EPs and ENs contacted, 502 completed the survey and were eligible for further analysis (30% response rate). Of the respondents, 233 (46%) were EPs and 269 (54%) were ENs, with ENs being significantly younger and with fewer years in practice. More than half reported experience caring for TIN patients (71% of ENs vs 61% of EPs; P = 0.002), but there were significant gaps in medical and non-medical knowledge. Attitudes toward TIN patients were generally positive, but differences in communication approaches were noted, with ENs significantly more likely than EPs to limit their communication with TIN patients to what was necessary (25% of ENs vs 17% of EPs; P = 0.006). Most respondents (55% of ENs and 58% of EPs) had no training in the management of TIN patients, with only 8% of EPs and 17% of ENs having received such training during their medical/nursing school education (P = 0.01). Both groups agreed that there is an urgent need to increase awareness of emergency medical care for TIN patients among ED staff.

Conclusion: Both emergency physicians and nurses in Germany demonstrated deficits in knowledge of and clinical preparedness to care for patients in the ED who identify as transgender, intersexual and non-binary, indicating a clear need for enhanced education, training, and institutional support to improve emergency care for this vulnerable patient population. [West J Emerg Med. 2024;25(6)1–9.]

Objectives: Management strategies for small bowel obstruction (SBO) vary from conservative approaches to surgical intervention. A known complication of surgery is the subsequent adhesions that can cause recurrent SBOs, longer hospital stays, and higher treatment costs. Our primary outcome was to identify independent risk factors that are associated with the decision for surgical intervention, and our secondary outcome was to describe characteristics of visits associated with complications.

Methods: This study was a single-center, retrospective chart review from a large, urban university hospital. We included adult patients admitted to the emergency department (ED) with the International Classification of Diseases, 10th Rev, codes for small bowel obstruction from June 1, 2017– May 30, 2019. Eligible covariates were demographics, radiological findings, clinical presentation, past medical history, and results of radiologic testing. We identified univariate associations of outcome and then performed a multivariate logistic regression to identify independent associations of each outcome. Finally, a backwards selection was used to determine the final model. We calculated odds ratios (OR) and 95%confidence intervals (CI) along with the area under the curve (AUC), as appropriate.

Results: A total of 530 patients met the study criteria; 148 (27.9%) underwent surgery of whom 35 (6.6%) had complications. We identified seven independent associations for the decision of surgery: abdominal distension (OR 0.27, 95% CI 0.10–0.62); gastrografin (OR 0.41, 95% CI 0.20–0.81); previous SBO (OR 0.42, 95% CI 0.26–0.66); higher Charlson Comorbidity Index score (OR 0.87, 95% CI 0.80–0.95); nasogastric decompression (OR 2.04, 95% CI 1.25–3.39), initial systolic blood pressure <100 mm Hg (OR 2.65, 95% CI 1.05–6.53); free fluid or volvulus/closed-loop obstruction on computed tomography (OR 7.95, 95% CI 4.25–15.39), with the AUC for the predictive model equaling 0.73.

Conclusion: We identified seven independent associations present in the ED associated with the decision for surgery. These associations are a step toward building better prediction models and improving decision-making in the ED, allowing for a more adequate treatment plan. 

Introduction: The American College of Emergency Physicians supports community- and hospital-based programs that intervene to prevent firearm-related injury. To this end, the distribution of firearm locks or storage devices in the emergency department (ED) may help achieve this target. To inform secure firearm storage programs for households with children and firearms, we examined firearm storage practices, device preferences, and cost tolerance among parents/caregivers of children.

Methods: Between April 2018–November 2019, we conducted and analyzed an in-person survey of 294 caregivers, aged ≥18, with both children and firearms in the home. Surveys assessed reasons for firearm ownership, storage practices and device preferences among five storage-device options, and prices participants were willing to pay for devices. Practices and preferences were examined by participant characteristics. We used logistic regression to estimate odds ratios and 95% confidence intervals for associations of interest.

Results: Most participants (73%) reported personal protection as a reason for owning firearms, and nearly 80% owned at least one firearm storage device. Over half (55%) owned cable locks, but only 36%of owners reported regularly using them. Rapid-access devices (electronic and biometric lockboxes) were less commonly owned (26%) but more likely to be regularly used (73%). The most highly rated storage device features were the following: the ability to store the firearm unloaded (87.3%); the ability to store the firearm loaded (79.1%); and device affordability (65%). Most participants (78%) preferred rapid-access devices over other options. Participants were willing to pay more for products that afforded rapid access to the firearm. Participants reported they would pay a median of $100 for a pushbutton rapid-access product ($80 retail), and $150 for a biometric lockbox ($210 retail).

Conclusion: Understanding the storage practices and preferences among firearm-owning households with children can help inform ED injury-prevention screening and firearm safety practice implementation. Our results suggest that rapid-access devices may be the most preferable firearm storage devices for distribution by secure storage programs, and costs are likely minimal given parental/caregiver willingness to pay.

Background: This is a systematic review investigating the correlation between seizures identifiable on electroencephalogram (EEG), clinical excitatory movements (CEM), and ketamine administration for procedural sedation.

Methods: We searched MEDLINE, EMBASE, Cochrane CENTRAL, and Web of Science in April 2021. Search terms included variations for ketamine, myoclonus, seizures, status epilepticus, and electroencephalography. Two independent reviewers assessed papers based on eligibility criteria, which included human studies where EEG recordings were obtained during ketamine administration.

Results: Eight papers were eligible for inclusion with 141 subjects (24 children). Seven studies (133 subjects) reported epilepsy history; 70% (94/133) of these subjects had a pre-existing epilepsy diagnosis. No (0/39) subjects without epilepsy and 28% (26/94) of subjects with epilepsy had electrographic seizures after ketamine administration. In four studies where pediatric and adult subjects could be separated, children with epilepsy had electrographic seizures in 60% (3/5) of cases compared to 28% (6/33) of cases of adults with epilepsy. Of the subjects with epilepsy, 14% (10/74) had CEMs vs 5% (1/21) in subjects without epilepsy. Most CEMs (9/11) were temporally correlated with electrographic seizures.

Conclusions: Our findings indicate that in subjects with epilepsy, electrographic seizures were frequently seen with ketamine administration and were correlated with CEMs. No seizure activity after ketamine was seen in subjects without epilepsy. While the clinical significance of these findings needs further investigation, clinicians may want to consider patients’ seizure history when providing counseling on the risks and benefits of ketamine sedation.

Background: TikTok has rapidly become one of the most extensively downloaded and used social media platforms worldwide. Our focus on emergency medicine (EM)-related content on TikTok is to identify what specific video characteristics result in higher degrees of audience engagement, defined in this study as a total of video likes, comments, and shares.

Methods: Five second-year medical students using newly created TikTok accounts independently downloaded the first 100 videos to appear using the hashtag #emergencymedicine. The videos were reviewed for 52 variables. We performed a multiple linear regression analysis to examine the relationship between the variables and video engagement.

Results: Of the examined videos, 45.8% (222/484) were produced by physicians (MD or DO). Approximately half, 50.0% (242/484), had an educational component, while 55.4% (268/484) of videos were judged to have an entertainment component. Preliminary findings indicate that among TikTok videos featuring #emergencymedicine, a statistically significant positive correlation exists between video engagement and the presence of a healthcare identifier, (ie, individuals wearing white coats or scrubs). No significant correlation was observed between video engagement and video creators’ self-identification as a healthcare professional, use of entertainment, or use of education. A notable negative correlation was identified between video engagement and the inclusion of music.

Conclusion: We identified qualities associated with negative and positive correlation with video engagement. For the 100 videos, only healthcare attire, such as wearing a white coat or scrubs, showed a significant positive correlation with engagement, while those with background music showed a negative correlation. Our study offers insight into how EM professionals can effectively use characteristics associated with higher engagement rates to relay information to a wider audience on TikTok.

Introduction: Medical device recalls are important to the practice of emergency medicine, as unsafe devices include many ubiquitous items in emergency care, such as vascular access devices, ventilators, infusion pumps, video laryngoscopes, pulse oximetry sensors, and implantable cardioverter defibrillators. Identification of dangerous medical devices as early as possible is necessary to minimize patient harms while avoiding false positives to prevent removal of safe devices from use. While the United States Food and Drug Administration (FDA) employs an adverse event reporting program (MedWatch) and database (MAUDE), other data sources and methods might have utility to identify potentially dangerous medical devices. Our objective was to evaluate the sensitivity, specificity, and accuracy of a machine learning (ML) algorithm using publicly available data to predict medical device recalls by the FDA.

Methods: We identified recalled medical devices (RMD) and non-recalled medical devices (NRMD) using the FDA’s website and online database. We constructed an ML algorithm (random forest regressor) that automatically searched Google Trends and PubMed for the RMDs and NRMDs. The algorithm was trained using 400 randomly selected devices and then tested using 100 unique random devices. The algorithm output a continuous value (0–1) for recall probability for each device, which were rounded for dichotomous analysis. We determined sensitivity, specificity, and accuracy for each of three time periods prior to recall (T-3, 6, or 12 months), using FDA recall status as the reference standard. The study adhered to relevant items of the Standards for Reporting Diagnostic accuracy studies (STARD) guidelines.

Results: Using a rounding threshold of 0.5, sensitivities for T-3, T-6, and T-12 were 89% (95%confidence interval [CI] 69–97), 90% (95% CI 70–97), and 75% (95% CI 53–89). Specificity was 100%(95% CI 95–100) for all three time periods. Accuracy was 98% (95% CI 93–99) for T-3 and T-6, and 95%(95% CI 89–99) for T-12. Using tailored thresholds yielded similar results.

Conclusion: An ML algorithm accurately predicted medical device recall status by the FDA with lead times as great as 12 months. Future research could incorporate longer lead times and data sources including FDA reports and prospectively test the ability of ML algorithms to predict FDA recall.

Objective: Our goal was to characterize a large group of children presenting to the emergency department (ED) with acute anaphylaxis, treated with intramuscular epinephrine (IM EPI) and a corticosteroid (CS), and to determine the impact of pharmacologic intervention on the rate and timing of biphasic reactions (BPR).

Methods: We reviewed consecutive children diagnosed with acute anaphylaxis managed in three EDs during a six-year period. All received IM EPI and CS, followed by monitoring for 4–6 hours post-treatment. We analyzed the rate and timing of BPR, comparing the intervals of 0–4vs4–48 hours after initiating therapy.

Results: During the study period, there were 371 cases of anaphylaxis, of which 357 (94%) received both IM EPI and CS. Of these, 49 (14%) manifested BPR [84% had received prehospital IM EPI] requiring at least one additional dose of IM EPI [14% required ≥2 additional doses]. All BPR episodes occurred within the 0–4 hour interval after initiating therapy, whereas no patient manifested a BPR requiring an additional dose of IM EPI during the 4–48 hours after initiating therapy (P =<0.001, 95% CI 0–1.3%). No patient returned to the ED with recurrence of anaphylaxis symptoms within 48 hours after discharge.

Conclusion: Approximately 1 in 7 children with anaphylaxis experience a biphasic reaction after receiving intramuscular epinephrine. Children with anaphylaxis who exhibit symptomatic resolution four hours following initiation of therapy have a low risk for subsequently developing BPR. Most BPR cases required only one additional dose of IM EPI to effect resolution. The rate of BPR in those receiving IM EPI and a corticosteroid is significantly lower >4 hours vs <4 hours after initiating therapy.

Introduction: Hyperkalemia, a potentially life-threatening electrolyte disturbance, is commonly encountered in the Emergency Department (ED). However, the frequency of factitious hyperkalemia, an artificially elevated potassium level in hyperkalemic ED patients, is unknown. This study aims to detect the rate of factitious hyperkalemia among patients with a potassium concentration of ≥5.0 mmol/l in an all-comer ED population.

Methods: This retrospective, monocentric chart review analyzed data of 2,440 ED patients who presented with a potassium concentration of ≥5.0 mmol/L in their initial whole blood or plasma sample, who also underwent a repeat potassium measurement on the same day. Two groups were established based on potassium levels in the initial and repeat blood tests: 1) True hyperkalemia, characterized by consistently elevated potassium levels in both the initial and repeat samples; and 2) Factitious hyperkalemia, defined by an elevated initial potassium level while the repeat blood test showed a normal potassium level. A subset of factitious hyperkalemia was spurious hyperkalemia. In spurious hyperkalemia, the initial blood sample showed an elevated potassium level with evidence of hemolysis, but a repeat test revealed a normal potassium level without evidence of hemolysis.

Results: Of the 2,440 patients, 1,576 (65%) had true hyperkalemia and 864 (35%) factitious hyperkalemia. Among the 864 patients with factitious hyperkalemia, 597 (69%) displayed hemolysis in their initial blood sample, indicating spurious hyperkalemia due to in-vitro hemolysis.

Conclusion: These data show that about one third of all hyperkalemic blood samples drawn in the ED were due to factitious hyperkalemia. The leading cause of factitious hyperkalemia was spurious hyperkalemia due to in-vitro hemolysis.