Showing papers in "Western Journal of Emergency Medicine in 2010"

High school students' perceptions of motivations for cyberbullying: an exploratory study.

Abstract: OBJECTIVES: Internet usage has increased in recent years resulting in a growing number of documented reports of cyberbullying. Despite the rise in cyberbullying incidents, there is a dearth of research regarding high school students' motivations for cyberbullying. The purpose of this study was to investigate high school students' perceptions of the motivations for cyberbullying. METHOD: We undertook an exploratory qualitative study with 20 high school students, conducting individual interviews using a semi-structured interview protocol. Data were analyzed using Grounded Theory. RESULTS: The developed coding hierarchy provides a framework to conceptualize motivations, which can be used to facilitate future research about motivations and to develop preventive interventions designed to thwart the negative effects of cyberbullying. The findings revealed that high school students more often identified internally motivated reasons for cyberbullying (e.g., redirect feelings) than externally motivated (no consequences, non-confrontational, target was different). CONCLUSION: Uncovering the motivations for cyberbullying should promote greater understanding of this phenomenon and potentially reduce the interpersonal violence that can result from it. By providing a framework that begins to clarify the internal and external factors motivating the behavior, there is enhanced potential to develop effective preventive interventions to prevent cyberbullying and its negative effects. Language: en

Paget-Schroetter Syndrome: Review of Pathogenesis and Treatment of Effort Thrombosis

Abstract: Effort thrombosis, or Paget-Schroetter Syndrome, refers to axillary-subclavian vein thrombosis associated with strenuous and repetitive activity of the upper extremities. Anatomical abnormalities at the thoracic outlet and repetitive trauma to the endothelium of the subclavian vein are key factors in its initiation and progression. The role of hereditary and acquired thrombophilias is unclear. The pathogenesis of effort thrombosis is thus distinct from other venous thromboembolic disorders. Doppler ultrasonography is the preferred initial test, while contrast venography remains the gold standard for diagnosis. Computed tomographic venography and magnetic resonance venography are comparable to conventional venography and are being increasingly used. Conservative management with anticoagulation alone is inadequate and leads to significant residual disability. An aggressive multimodal treatment strategy consisting of catheter-directed thrombolysis, with or without early thoracic outlet decompression, is essential for optimizing outcomes. Despite excellent insights into its pathogenesis and advances in treatment, a significant number of patients with effort thrombosis continue to be treated suboptimally. Hence, there is an urgent need for increasing physician awareness about risk factors, etiology and the management of this unique and relatively infrequent disorder.

Alcohol outlets and violent crime in Washington D.C

Abstract: Objective: Alcohol is more likely than any other drug to be involved in substance-related violence. In 2000 violence-related and self-directed injuries accounted for an estimated $37 billion and $33 billion in productivity losses and medical treatment, respectively. A review of emergency department data revealed violence and clinically identified trauma-related injuries have the strongest correlation among alcohol-dependent injuries. At the environmental level there is a relationship between alcohol outlet density and violent crime. A limited number of studies have examined the relationship between alcohol outlet type and the components of violent crime. The aim of this study is to examine the relationship between the aggregate components of violent crime and alcohol outlet density by type of outlet. Methods: For this study we used Washington, D.C. census tract data from the 2000 census to examine neighborhood characteristics. Alcohol outlet, violent crime, and population-level data for Washington, D.C. were drawn from various official yet publicly available sources. We developed an analytic database to examine the relationship between alcohol outlet category and four types of violent crime. After estimating spatial correlation and determining spatial dependence, we used a negative binomial regression analysis to assess the alcohol availability-violent crime association, while controlling for structural correlates of violence. Results: Independent of alternative structural correlates of violent crime, including the prevalence of weapons and illicit drugs, community-level alcohol outlet density is significantly associated with assaultive violence. Outlets were significantly related to robbery, assault, and sexual offenses. In addition, the relationship among on-premise and off-premise outlets varied across violent crime categories. Conclusion: In Washington, D.C., alcohol outlet density is significantly associated with the violent crimes. The science regarding alcohol outlet density and alcohol-related harms has clearly identified the use of limiting outlet density to reduce the associated adverse health consequences. Moreover, the disproportionate burden among poor urban and minority communities underscores the urgency to develop context-appropriate policies to regulate the functioning of current alcohol outlet establishments and to prevent the proliferation of future outlets. [West J Emerg Med. 2010; 11(3): 284-291.]

The Impact of Built Environment on Pedestrian Crashes and the Identification of Crash Clusters on an Urban University Campus

Abstract: Objectives: Motor vehicle-pedestrian crash is a significant public health concern. The urban campus of Georgia State University poses unique challenges due to a large number of students and university employees. The objectives of this study are twofold: (1) to examine the correlation between specific features of the built environment on and around the University campus and pedestrian crashes; and (2) to identify crash clusters in the study area using network-based geospatial techniques. Methods: We obtained pedestrian crash data (n=119) from 2003 to 2007 from Georgia Department of Transportation and evaluated environmental features pertaining to the road infrastructure, pedestrian infrastructure and streetscape for each road segment and intersection. Prevalence rate of each feature with pedestrian crashes present was calculated. We used network-based Kernel Density Estimation to identify the high density road segments and intersections, then used network-based K-function to examine the clustering of pedestrian crashes. Results: Over 50% of the crosswalk signs, pedestrian signals, public transit, and location branding signs (more than three) at intersections involved pedestrian crashes. More than half of wider streets (greater than 29 feet), two-way streets, and streets in good condition had pedestrian crashes present. Crashes occurred more frequently in road segments with strong street compactness and mixed land use present and were significantly (p<0.05) clustered in these high-density zones. Conclusions: Findings can be used to understand the correlation between built environment and pedestrian safety, to prioritize the high-density zones for intervention efforts, and to formulate research hypotheses for investigating pedestrian crashes. [West J Emerg Med. 2010; 11(3): 295-302.]

Reporting of Intimate Partner Violence among Men Who Have Sex with Men in an Online Survey

Abstract: Objective: A growing body of literature suggests that IPV occurs within same-sex relationships and that members of the LGBT community face a number of unique challenges in accessing IPV related services. This paper examines the use of an on-line survey, marketed through a popular social networking site, to collect data on the experience and perpetration of IPV among men who have sex with men (MSM) in the US. Methods: Internet-using MSM were recruited through selective placement of banner advertisements on MySpace.com. Participants were eligible for the baseline survey if they were males ≥ 18 years of age, and reported at least one male sex partner in the last 12 months. In total 16, 597 men responded to the ad, of which 11, 681 were eligible for the study, and 5602 completed the questionnaire: in total 543 men completed the follow-up survey which included questions on the experience and perpetration of IPV. The final analysis sample was 402 MSM. Results: The prevalence of violence among the sample was relatively high: 11.8% of men reported physical violence from a current male partner, and about 4% reported experiencing coerced sex. Reporting of perpetration of violence against a partner was generally lower, with approximately 7% reporting perpetrating physical violence and less than 1% reporting perpetration of sexual violence. Conclusion: The results presented here find lower levels of experiencing both physical and sexual IPV than have been shown in previous studies, yet show relatively high levels of reporting of perpetration of IPV. Collecting IPV data through surveys administered through social networking sites is feasible and provides a new opportunity to reach currently over-looked populations in IPV research.

Spontaneous Rectus Sheath Hematoma

Abstract: Abdominal wall pathology is a frequently overlooked cause of acute abdomen. Increasing use of antiplatelet and anticoagulant therapies has led to an increase in the incidence of spontaneous rectus sheath hematoma (RSH). A high index of suspicion is needed for diagnosis as it can closely mimic other causes of acute abdomen. Herein, we report a case of RSH presenting with abdominal pain in which there was a significant delay in diagnosis. We wish to highlight the need to increase awareness among primary and emergency physicians about considering RSH in the initial differential diagnoses of abdominal pain.

Chlorine gas: an evolving hazardous material threat and unconventional weapon

Abstract: Chlorine gas represents a hazardous material threat from industrial accidents and as a terrorist weapon. This review will summarize recent events involving chlorine disasters and its use by terrorists, discuss pre-hospital considerations and suggest strategies for the initial management for acute chlorine exposure events.

Variability in Ultrasound Education among Emergency Medicine Residencies

Abstract: Objective: Education in emergency ultrasound (EUS) has become an essential part of emergency medicine (EM) resident training. In 2009, comprehensive residency training guidelines were published to ensure proficiency in ultrasound education. The American College of Emergency Physicians (ACEP) recommends that 150 ultrasound exams be performed for physician competency. Our goal is to evaluate the current ultrasound practices among EM residency programs and assess the need for further formalization of EUS training. Methods: We generated a survey using an online survey tool and administered via the internet. The survey consisted of 25 questions that included multiple choice and free text answers. These online survey links were sent via email to EM ultrasound directors at all 149 American College of Graduate Medical Education EM residency programs in April 2008. We surveyed programs regarding EUS curriculum and residency proficiency requirements and descriptive statistics were used to report the survey findings. Results: Sixty-five residency programs responded to the survey. The average number of ultrasound exams required by programs for EUS competency was 137 scans. However, the majority of programs 42/65 (64%) require their residents to obtain 150 scans or greater for competency. Fifty-one out of 64 (79%) programs reported having a structured ultrasound curriculum while 14/64 (21%) of programs reported that EUS training is primarily resident self-directed. In terms of faculty credentialing, 29/62 (47%) of residency programs have greater than 50% of faculty credentialed. Forty-four out of 61 (72%) programs make EUS a required rotation. Thirty-four out of 63 (54%) programs felt that they were meeting all their goals for resident EUS education. Conclusion: Currently discrepancies exist between EM residency programs in ultrasound curriculum and perceived needs for achieving proficiency in EUS. Although a majority of residency programs require 150 ultrasound exams or more to achieve resident competency, overall the average number of scans required by all programs is 137 exams. This number is less than that recommended by ACEP for physician competency. These data suggest that guidelines are needed to help standardize ultrasound training for all EM residency programs. [West J Emerg Med 2010; 11(4):314-318.]

Nonreciprocal and Reciprocal Dating Violence and Injury Occurrence among Urban Youth

Abstract: Objective: Dating violence is a significant health problem among youth that leads to adverse health outcomes, including injuries. Reciprocal violence (perpetrated by both partners) is associated with increased injury in adults, but very little is known about the prevalence and context for reciprocal violence, as well as injury rates, among youth. We sought to determine the prevalence and scope of reciprocal dating violence and injury occurrence among urban youth in a high-risk community. Methods: Analyses were based on data from the Youth Violence Survey, conducted in 2004, and administered to over 80% of public school students in grades 7, 9, 11, and 12 (N=4,131)

Intimate Partner Violence, Physical Health, Posttraumatic Stress Disorder, Depression, and Quality of Life in Latinas

Abstract: Objectives: The purposes of this exploratory study were to a) describe physical health symptoms and diagnoses in abused immigrant Latinas, b) explore the relationships between the women’s physical health and their experiences of intimate partner violence (IPV), their history of childhood trauma and immigration status, and c) explore the correlations between their physical health, health-related quality of life (HRQOL), and mental health, specifically symptoms of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD).Methods: The convenience sample (n=33) for this cross-sectional descriptive study consisted of Latino women receiving emergency shelter and community-based services at a domestic violence services agency in the northeastern U.S. We used Pearson product-moment correlation coefficients to analyze the relationships between physical health variables and IPV type and severity, childhood and adulthood sexual abuse, and HRQOL.Results: All of the women experienced threatened abuse. More than two-thirds experienced moderate to severe psychological abuse, moderate to severe physical abuse, and/or sexual abuse. Twenty women experienced all three types. Women endorsed one or more items in neuromuscular (69.7%), gastrointestinal (63.6%), and genitourinary/gynecologic (45.5%) groupings. Pain was the most reported symptom: bodily pain in previous month (60%), repeated neck or back pain (54.5%), severe/frequent headaches (54.5%), and pelvic pain (21.2%). Eighty-one percent of women endorsed at least one pain item (mean=2.56), and the same number reported difficulty falling asleep or staying asleep. Pain and sleeping difficulty, the two most frequently reported symptoms, were consistently and highly correlated with PTSD and MDD diagnoses and symptom severity and HRQOL. Childhood sexual abuse was significantly correlated with total pain symptoms (r=0.606, p=0.000) and difficulty sleeping (from the PTSD scale) (r=0.349, p=0.046). Both pain (r=0.400, p=0.023) and sleeping difficulty (r=0.467, p=0.006) were also strongly correlated with undocumented immigration status. Conclusion: Detailed assessment of patients with pain and sleep disorders can help identify IPV and its mental health sequelae, PTSD and MDD. Accurate identification of the root causes and pathways of the health burden carried by victims and survivors of IPV, who are vulnerable to persisting health problems without adequate healthcare, is critical in both clinical practice and research. [West J Emerg Med. 2010; 11(3):247-251.]INTRODUCTIONNearly one in four women have been physically assaulted or raped by an intimate partner in their lifetime.

Frequency of incidental findings on computed tomography of trauma patients.

Abstract: Objective: To determine the incidence and frequency of follow-up instructions for incidental findings on computed tomography (CT) scanning of the abdomen and pelvis in trauma patients. Methods: We performed a retrospective chart review of all adult patients triaged to the trauma service at a Level I trauma center between July 1, 2003 and June 30, 2004. Included patients were 16 years of age and older who underwent abdomen and pelvic CT scans as part of their primary evaluation. We excluded patients under the age of 16 years, patients unable to complete radiographic studies due to deterioration in condition, patients with missing CT scan reports, and transferred patients who had CT scans done at outside facilities. Results: A total of 1,633 patients presented to the trauma service during the study period; 922 patients met inclusion criteria. Of these, 392 had incidental findings noted on the formal radiology

Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography.

Abstract: Objective: Emergency department (ED) frequent users account for a large number of annual ED visits and often receive radiological studies as a part of their evaluation. We report a pilot study of a case management program for ED frequent users to reduce ED usage and radiation exposure. Methods: This observational retrospective study was performed at a community hospital ED. Between May 2006 and April 2008, 96 patients were enrolled in a case management program and were followed through November 2008. The case management program consisted of a multi-disciplinary team of physicians, nurses, social services and specialists in pain management and behavioral health. Patients were enrolled if they had five or more visits to the ED in the previous month, if a concern about a patient’s ED use was raised by staff, or if they were identified by the California prescription monitoring program. Case management addressed specific patient issues and assisted with receiving consistent outpatient care. The number of ED visits per patient and the number of radiological studies at each of these visits was recorded. When reviewing data for analysis, we used the number of total images in all computed tomography (CT) scans during the given time period. Results: In the six months prior to enrollment, patients averaged 2.3 ED visits per patient per month. In the six months after enrollment, patients averaged 0.6 ED visits per patient per month (P<0.0001), and all visits after enrollment up to November 2008 averaged 0.4 visits per patient per month (P<0.0001). In the six months prior to enrollment, these patients averaged 25.6 CT images per patient per month. In the six months after enrollment, patients averaged 10.2 CT images per patient per month (P=0.001), and all CT images after enrollment up to November 2008 averaged 8.1 CT images per patient per month (P=0.0001). This represents a decrease in ED use by 83% and a decrease in radiation exposure by 67%. Conclusion: Case management can significantly reduce ED use by frequent users, and can also decrease radiation exposure from diagnostic imaging. [West J Emerg Med. 2010; 11(4): 336-343].

Emergency department crowding: factors influencing flow.

Abstract: Background: The objective of this study was to evaluate those factors, both intrinsic and extrinsic to the emergency department (ED) that influence two specific components of throughput: “door-to-doctor” time and dwell time. Methods: We used a prospective observational study design to determine the variables that played a significant role in determining ED flow. All adult patients seen or waiting to be seen in the ED were observed at 8pm (Monday-Friday) during a three-month period. Variables measured included daily ED volume, patient acuity, staffing, ED occupancy, daily admissions, ED boarder volume, hospital volume, and intensive care unit volume. Both log-rank tests and time-to-wait (survival) proportional-hazard regression models were fitted to determine which variables were most significant in predicting “door-to-doctor” and dwell times, with full account of the censoring for some patients. Results: We captured 1,543 patients during our study period, representing 27% of total daily volume. The ED operated at an average of 85% capacity (61-102%) with an average of 27% boarding. Median “door-to-doctor” time was 1.8 hours, with the biggest influence being triage category, day of the week, and ED occupancy. Median dwell time was 5.5 hours with similar variable influences. Conclusion: The largest contributors to decreased patient flow through the ED at our institution were triage category, ED occupancy, and day of the week. Although the statistically significant factors influencing patient throughput at our institution involve problems with inflow, an increase in ED occupancy could be due to substantial outflow obstruction and may indicate the necessity for increased capacity both within the ED and hospital. [West J Emerg Med. 2010; 11(1):10-15]

Competitive Wrestling-related Injuries in School Aged Athletes in U.S. Emergency Departments.

Abstract: 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. Language: en

Use of health information technology to manage frequently presenting emergency department patients.

Abstract: Objective: To determine if the effective use of Health Information Technologies (HIT) and the Electronic Medical Record (EMR) affects emergency department (ED) usage in a complicated frequently presenting patient population. Methods: A retrospective, observational study of 45 patients enrolled in our Frequent User Program called Community Resources for Emergency Department Overuse (CREDO) between June 2005 and July 2007. The study was conducted at an urban hospital with greater than 95,000 annual visits. Patients served as their own historical controls. In this pre-post study, the pre-intervention control period was determined by the number of months the patient had been enrolled in the program. The pre- and post-intervention time periods were the same for each patient but varied between patients. The intervention included using HIT to identify the most frequently presenting patients and creating individualized care plans for those patients. The care plans were made available through the EMR to all healthcare providers. Study variables in this study intervention included ED charges, lab studies ordered, number of ED visits, length of stay (LOS), and Total Emergency Department Contact Time (TEDCT), which is the product of the number of visits and the LOS. We analyzed these variables using paired T-tests. This study was approved by the institutional review board. Results: Forty-five patients were enrolled, but nine were excluded for no post enrollment visits; thus, statistical analysis was conducted with n=36. The ED charges decreased by 24% from $64,721 to $49,208 (p=0.049). The number of lab studies ordered decreased by 28% from 1847 to 1328 (p=0.04). The average number of ED visits/patient decreased by 25% from 67.4 to 50.5 (p=0.046). The TEDCT decreased by 39% from 443.7 hours to 270.6 hours (p=0.003). Conclusion: In this pre-post analysis of an intervention targeting ED frequent users, the use of HIT and the EMR to identify patients and store easily accessible care plans significantly reduced ED charges, labs ordered, number of ED visits, and the TEDCT. [West J Emerg Med 2010; 11(4):348-353.]

Adaptation of EPEC-EM ™ Curriculum in a Residency with Asynchronous Learning

Abstract: 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.]

Correlation Between Intimate Partner Violence Victimization and Risk of Substance Abuse and Depression among African-American Women in an Urban Emergency Department

Abstract: OBJECTIVE: To assess rates of substance abuse (including tobacco, alcohol, and drug abuse) as well as rates of intimate partner violence (IPV) among African-American women seen in an urban emergency department (ED). METHODS: Eligible participants included all African-American women between the ages of 21-55 years old who were seen in an urban ED for any complaint and triaged to the waiting room. Eligible women who consented to participate completed a computer-based survey that focused on demographic information and general health questions, as well as standardized instruments to screen for alcohol abuse, tobacco abuse, and illicit drug use. This analysis uses results from a larger study evaluating the effects of providing patients with targeted educational literature based on the results of their screening. RESULTS: Six-hundred ten women were surveyed; 430 women reported being in a relationship in the past year and among these, 85 women (20%) screened positive for IPV. Women who screened positive for IPV were significantly more likely to also screen positive for tobacco abuse (56% vs. 37.5%, p Language: en

Chronic or recurrent pain in the emergency department: national telephone survey of patient experience.

Abstract: 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, twothirds 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

The base of the pyramid.

Abstract: Recently, after 17 eventful and rewarding years at Emory University, I decided it was time for a change My son was about to graduate from college, and both the injury prevention center and academic department I had founded were flourishing under my successors With a strong sense of anticipation, my wife and I set out to write a new chapter of our lives in Washington, DC, where I had agreed to join the RAND Corporation as the Paul O’Neill-Alcoa Chair of Policy Analysis One month into my new job, I awoke one Friday morning refreshed and ready to go As I stood in the shower, I contemplated the upcoming events of the day That morning, I was scheduled to meet with Rep Jim Cooper, (D-TN) an expert on health policy and a leading “Blue Dog” in the US House of Representatives That afternoon, I had a much-anticipated meeting with Dr Carolyn Clancy, Director of the Agency for Healthcare Research and Quality (AHRQ) Momentarily distracted by these thoughts, my capacity to perform a necessary task – maintaining my footing in the slippery bathtub of my rental house—momentarily dipped below the threshold required for adequate performance That was all it took In an instant, my feet slid apart Losing my balance, I spun about and heavily fell against the edge of the tub The crack as my chest struck porcelain was both audible and palpable Alarmed by my howls of pain, followed by a torrent of curses, my wife bolted from bed A lawyer by training, 27 years of marriage to an emergency physician had taught her to assess what’s important Airway, breathing, circulation? Intact Mental status? Conscious and coherent (albeit profanely so) Motor exam? Intact Spine or head trauma? Negative Convinced I would survive; she went back to bed, leaving me to fend for myself Determined that I was not going to let a little chest trauma spoil my day, I painfully dressed for work But as I headed downstairs, I began to feel sick That’s when I realized I might be more seriously injured than I first thought Meekly, I awoke my wife and asked her to drive me to the emergency department (ED) for a chest X-ray It confirmed my worst fears In addition to two fractured ribs, I had a traumatic pneumothorax Each year, 1 in 4 Americans is injured seriously enough to require medical attention1 The most careful among us – even emergency physicians and injury control center directors – can become momentarily distracted Depending on the amount of force unleashed, the resulting damage may be relatively minor or catastrophic Over the past few decades, the field of injury control has devised a range of techniques to prevent injuries countless and reduce the severity of those that occur We’ve discovered a wide range of educational techniques to promote safe behavior When education is not enough to inspire universal adoption of effective countermeasures, we’ve shown that compliance of simple and non-intrusive actions (such as buckling a safety belt or wearing a motorcycle helmet) can be boosted through high-visibility enforcement And we’ve learned to prevent and reduce injuries by engineering safety into consumer products, motor vehicles and many built environments1 A few years ago, a well-engineered motor vehicle prevented my son from sustaining a serious injury and possibly saved his life2 Untold thousands, if not millions, are alive today thanks to the science of injury control This issue of the Western Journal of Emergency Medicine demonstrates that the field of control continues to evolve Under the leadership of Dr Debra Houry, a gifted emergency physician who succeeded me 4 years ago as director of the Emory Center for Injury Control, the tiny program two colleagues and I founded in 1993 has grown to involve over 80 faculty and staff at nine Georgia colleges and universities and numerous community partners Recognized as a “Collaborating Center” by the Pan American and World Health Organizations, the Emory CIC was recently designated an Injury Control Research Center (ICRC) by the Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control Emory’s program and the other CDC funded ICRCs are committed to discovering practical strategies that make a difference and translating them into every day practice Some readers of this journal might wonder, “What does this have to do with emergency medicine?” The answer is “Plenty” Emergency physicians specialize in making time-critical diagnoses and quickly initiating care to alter the progression of disease Every time we treat an asthmatic child, an adult with an acute ST segment-elevation MI or an adolescent with sepsis, we are acting to interrupt a harmful chain of events that will otherwise lead to severe illness or death But the case of trauma, we don’t have days, hours or minutes to act The event occurs in the blink of an eye, and is over long before the patient arrives in the ED Sometimes we can limit the consequences of injury through timely action and take measures to facilitate the healing process, but our capacity to fully reverse the consequences of injury is limited Try as we might, we cannot unbreak a bone, restore a damaged brain or bring the dead back to life3 The best strategy, by far, is prevention That’s why injury control is important, and why it should matter to emergency physicians and other emergency care practitioners We are ideally placed to advance the science and practice of injury control through bedside (and roadside) counseling of our patients, by advocating sound public policies and by conducting groundbreaking biomechanical, epidemiological and prevention research And we would be wise to direct our efforts at the entire spectrum of injury; not just those that are particularly severe My personal mishap is instructive Fortunately, my rib fractures and pneumothorax were not life-threatening, but they were costly and disabling After initially resisting surgical intervention, I reluctantly agreed to a chest tube and 2-day hospital stay I did not fully recover for several weeks The charges for my care are rolling in now Trust me - American healthcare isn’t cheap I readily concede that my fall could have been worse—after all, I didn’t fracture my neck or sustain an epidural hematoma—but it was bad enough People like me form the base of the injury pyramid4 Our injuries are non-fatal and many, like mine, are only mildly disabling But we account for almost one-quarter of the roughly 123 million visits Americans make to ED each year1 We also contribute the rising costs of healthcare And our injuries are every bit as preventable as those that garner the headlines When I returned home from the hospital, my wife presented me with a gift—a cheap plastic bathmat covered with suction cups that help it firmly attach to the floor of a tub When I went to work the next day, I found that my RAND colleagues had sent me a second one, covered with autographs and “get well” messages Now, I can daydream in the shower all I want, because my footing is secure Cost: about $600 retail Value: Priceless

Ultrasound-Guided Three-In-One Nerve Block for Femur Fractures

Abstract: Femur fractures typically affect elderly patients with multiple co-morbidities. Pain control can be difficult, requiring intensive nursing and physician care as elderly patients may manifest cardiovascular and respiratory complications from opiate administration. Ultrasound (US)-guided three-in-one (3-in-1) femoral nerve block (FNB) is an option for pain management in patients with femur fractures, as it provides regional anesthesia to the femoral, obturator and lateral cutaneous nerves. Our goal is to provide medical education regarding the use of US-guided 3-in-1FNB as a rapid and easy procedure that may provide optimal patient care in patients with femur fractures.

Emergency Department Chief Complaint and Diagnosis Data to Detect Influenza-Like Illness with an Electronic Medical Record

Abstract: Background: The purpose of syndromic surveillance is early detection of a disease outbreak. Such systems rely on the earliest data, usually chief complaint. The growing use of electronic medical records (EMR) raises the possibility that other data, such as emergency department (ED) diagnosis, may provide more specific information without significant delay, and might be more effective in detecting outbreaks if mechanisms are in place to monitor and report these data.

Fatal dysrhythmia following potassium replacement for hypokalemic periodic paralysis.

Abstract: We present a case of fatal rebound hyperkalemia in a patient with thyrotoxic periodic paralysis (TPP) treated with potassium supplementation. Although TPP is a rare hyperthyroidism-related endocrine disorder seen predominantly in men of Asian origin, the diagnosis should be considered in patients of non-Asian origins presenting with hypokalemia, muscle weakness or acute paralysis. The condition may present as a life threatening emergency and unfamiliarity with the disease could result in a fatal outcome. Immediate therapy with potassium chloride supplementation may foster a rapid recovery of muscle strength and prevent cardiac arrhythmias secondary to hypokalemia, but with a risk of rebound hyperkalemia.

Children at Risk for Suicide Attempt and Attempt-related Injuries: Findings from the 2007 Youth Risk Behavior Survey.

Abstract: Purpose: The current study examines the associations between a range of risk factors and reports of suicide attempts, and attempts requiring medical care in a nationally representative study of high school students. The goal is to examine sex differences in the risk factors that are associated with suicide attempts and attempt-related injuries requiring treatment by a health-care provider. Methods: Data from the 2007 Youth Risk Behavior Survey for students in grades 9-12 were used to assess the prevalence and risk factors for suicidal behavior as well as differences in these for boys and girls. Cross-sectional multivariate logistic regression analyses were computed to determine the most important risk factors for suicide attempts and for suicide attempts requiring medical care for the sample overall and also stratified for boys and for girls. Results: Overall, 6.9% of adolescents attempted suicide (9.3% of girls versus 4.6% of boys). Girls were more likely than boys to report a suicide attempt in the past year (Adj.OR=2.89). Among girls, sadness (Adj.OR=5.74), weapon carrying (Adj.OR=1.48), dating violence (Adj.OR=1.60), forced sex (Adj.OR=1.72), and huffing glue (Adj.OR=2.04) were significantly associated with suicide attempts. Among boys, sadness (Adj.OR=10.96), weapon carrying (Adj.OR=1.66), forced sex (Adj.OR=2.60), huffing glue (OR=1.63), hard drug use (Adj.OR=2.18), and sports involvement (Adj.OR=1.52) were significantly associated with suicide attempts. Conclusions: These findings demonstrate similarities and differences in terms of the modifiable risk factors that increase risk for suicide attempts among boys and girls. In terms of the differences between boys and girls, hard drug use and sports involvement may be important factors for suicide prevention strategies that are directed specifically towards boys, while dating violence victimization may be an important risk factor to address for girls. Overall, these findings can help guide prevention, clinical practice, and intervention strategies to prevent suicidal behaviors among adolescents. [West J Emerg Med. 2010; 11(3): 258-264.]

Occupancy rates and emergency department work index scores correlate with leaving without being seen.

Abstract: Objective: Two crowding metrics are often used to measure emergency department (ED) crowding: the occupancy rate and the emergency department work index (EDWIN) score. To evaluate these metrics for applicability in our community ED, we sought to measure their correlation with the number of patients who left without being seen (LWBS) and determine if either, or both, correlated with our daily LWBS rate. We hypothesized a statistically significant positive correlation between the number of patients who LWBS and both crowding metrics.

The physiologic effects of multiple simultaneous electronic control device discharges.

Abstract: OBJECTIVES: Law enforcement and military personnel use electronic control devices to control non-compliant and actively resistive subjects. The TASER((R)) Shockwave is a new electronic control device designed specifically as an area denial device capable of delivering multiple simultaneous discharges. This is the first study to examine the effects of multiple simultaneous device discharges in humans. METHODS: Volunteers were exposed to multiple (two to three), simultaneous 5-second discharges from the Shockwave device to the chest, back, chest to abdomen, or thighs. Blood was analyzed before and after discharge for pH, lactate, potassium, creatine kinase (CK), and troponin. Continuous spirometry was performed before, during, and after the discharge. In addition, electrocardiograms (ECGs) before and after discharge were recorded, and echocardiography was used to determine the rhythm during discharge. RESULTS: Small elevations of lactate occurred. Moderate increases in CK at 24 hours occurred and appeared to be related to the number of simultaneous discharges. There was a trend to a decrease in minute ventilation in the volunteers exposed to two simultaneous discharges, but it did not reach statistical significance. ECG changes only reflected an increase in vagal tone, and there was no evidence of capture by echocardiography. Five-second, simultaneous, multiple exposures to the TASER Shockwave device were reasonably tolerated by our human volunteers. CONCLUSION: Our study suggests that this device may have a reasonable risk/benefit ratio when used to protect an area from a threat. Language: en

Improving diagnostic accuracy of anaphylaxis in the acute care setting.

Abstract: 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.

Randomized controlled trial of prophylactic antibiotics for dog bites with refined cost model

Abstract: 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, double-blind 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. Language: en

Ileocecal intussusception in the adult population: case series of two patients.

Abstract: Background: Intussusception is a condition found primarily in the pediatric population. In the adult population, however, intussusception is usually due to a pathological process, with a higher risk of bowel obstruction, vascular compromise, inflammatory changes, ischemia, and necrosis. Radiographic and sonographic evidence can aid in the diagnosis. Surgical intervention involving resection of affected bowel is the standard of care in adult cases of intussusception. Case Reports: We present the case of a 21-year-old female who presented to the Emergency Department with diffuse cramping abdominal pain and distention. Workup revealed ileocecal intussusception, with a prior appendectomy scar serving as the lead point discovered during exploratory laparotomy. We also present the case of a 66-year-old male, who presented with one week of intermittent lower abdominal pain associated with several episodes of nausea and vomiting. Workup revealed ileocolic intussusception secondary to adenocarcinoma of the right colon, confirmed upon exploratory laparotomy with subsequent right hemicolectomy. Conclusion: In the adult population, intussusception is usually caused by a lead point, with subsequent telescoping of one part of the bowel into an adjacent segment. While intussusception can occur in any part of the bowel, it usually occurs between a freely moving segment and either a retroperitoneal or an adhesion-fixed segment. The etiology may be associated with pathological processes such as carcinoma or iatrogenic causes, such as scars or adhesions from prior surgeries. The cases presented here demonstrate important etiologies of abdominal pain in adult patients. Along with gynecological etiologies of lower quadrant abdominal pain in female patients, it is important for the emergency physician to expand the differential diagnosis to include other causes, such as intussusceptions, especially given the symptoms that could be associated with bowel obstruction. [West J Emerg Med. 2010;197-200.]

Cholinergic crisis after rodenticide poisoning.

Abstract: 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. Language: en

Comparability of Results between Point-of-Care and Automated Instruments to Measure B-type Natriuretic Peptide

Abstract: OBJECTIVES Heart failure is one of the leading causes of death in the U.S. The incorporation of B-type natriuretic peptide (BNP) measurements when triaging patients presenting with shortness of breath has improved the diagnostic and prognostic ability of physicians. Currently, there are no point-of-care systems for quantifying BNP that can be used without sacrificing accuracy. We compared the analytical performance of the Abbott i-STAT analyzer, a handheld point-of-care system for measuring BNP, with the lab-based system, the Abbott ARCHITECT. METHODS One-hundred fifty samples were collected from three clinical settings: 41 from the Emergency Department, 58 from the inpatient wards, and 51 from heart failure outpatient clinics. Linear regression and bias difference analyses were run to evaluate the accuracy of the i-STAT. Correlation between the i-STAT and Architect BNP values were made with values of BNP. RESULTS The correlation coefficient was r=0.977 (N=150, p<.0001). The average bias was significant (-36) and there were concentration-dependent differences at higher BNP values. Precision of the i-STAT was poor compared to the lab-based platform. CONCLUSION Although the precision of the i-STAT was poor, there was good clinical agreement between the i-STAT and the lab-based platform.