Showing papers in "Western Journal of Emergency Medicine in 2012"

Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup

Abstract: Agitation is an acute behavioral emergency requiring immediate intervention. Traditional methods of treating agitated patients, ie, routine restraints and involuntary medication, have been replaced with a much greater emphasis on a noncoercive approach. Experienced practitioners have found that if such interventions are undertaken with genuine commitment, successful outcomes can occur far more often than previously thought possible. In the new paradigm, a 3-step approach is used. First, the patient is verbally engaged; then a collaborative relationship is established; and, finally, the patient is verbally de-escalated out of the agitated state. Verbal de-escalation is usually the key to engaging the patient and helping him become an active partner in his evaluation and treatment; although, we also recognize that in some cases nonverbal approaches, such as voluntary medication and environment planning, are also important. When working with an agitated patient, there are 4 main objectives: (1) ensure the safety of the patient, staff, and others in the area; (2) help the patient manage his emotions and distress and maintain or regain control of his behavior; (3) avoid the use of restraint when at all possible; and (4) avoid coercive interventions that escalate agitation. The authors detail the proper foundations for appropriate training for de-escalation and provide intervention guidelines, using the “10 domains of de-escalation.”

The Psychopharmacology of Agitation: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup

Abstract: Agitation is common in the medical and psychiatric emergency department, and appropriate management of agitation is a core competency for emergency clinicians. In this article, the authors review the use of a variety of first-generation antipsychotic drugs, second-generation antipsychotic drugs, and benzodiazepines for treatment of acute agitation, and propose specific guidelines for treatment of agitation associated with a variety of conditions, including acute intoxication, psychiatric illness, delirium, and multiple or idiopathic causes. Pharmacologic treatment of agitation should be based on an assessment of the most likely cause of the agitation. If agitation results from a delirium or other medical condition, clinicians should first attempt to treat the underlying cause instead of simply medicating with antipsychotics or benzodiazepines.

Use and Avoidance of Seclusion and Restraint: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup

Abstract: Issues surrounding reduction and/or elimination of episodes of seclusion and restraint for patients with behavioral problems in crisis clinics, emergency departments, inpatient psychiatric units, and specialized psychiatric emergency services continue to be an area of concern and debate among mental health clinicians. An important underlying principle of Project BETA (Best practices in Evaluation and Treatment of Agitation) is noncoercive de-escalation as the intervention of choice in the management of acute agitation and threatening behavior. In this article, the authors discuss several aspects of seclusion and restraint, including review of the Centers for Medicare and Medicaid Services guidelines regulating their use in medical behavioral settings, negative consequences of this intervention to patients and staff, and a review of quality improvement and risk management strategies that have been effective in decreasing their use in various treatment settings. An algorithm designed to help the clinician determine when seclusion or restraint is most appropriate is introduced. The authors conclude that the specialized psychiatric emergency services and emergency departments, because of their treatment primarily of acute patients, may not be able to entirely eliminate the use of seclusion and restraint events, but these programs can adopt strategies to reduce the utilization rate of these interventions.

Bystander motivation in bullying incidents: to intervene or not to intervene?

Abstract: IntroductionThis research sought to extend knowledge about bystanders in bullying situations with a focus on the motivations that lead them to different responses. The 2 primary goals of this study were to investigate the reasons for children's decisions to help or not to help a victim when witnessing bullying, and to generate a grounded theory (or conceptual framework) of bystander motivation in bullying situations.MethodsThirty students ranging in age from 9 to 15 years (M = 11.9; SD = 1.7) from an elementary and middle school in the southeastern United States participated in this study. Open- ended, semi-structured interviews were used, and sessions ranged from 30 to 45 minutes. We conducted qualitative methodology and analyses to gain an in-depth understanding of children's perspectives and concerns when witnessing bullying.ResultsA key finding was a conceptual framework of bystander motivation to intervene in bullying situations suggesting that deciding whether to help or not help the victim in a bullying situation depends on how bystanders define and evaluate the situation, the social context, and their own agency. Qualitative analysis revealed 5 themes related to bystander motives and included: interpretation of harm in the bullying situation, emotional reactions, social evaluating, moral evaluating, and intervention self-efficacy.ConclusionGiven the themes that emerged surrounding bystanders' motives to intervene or abstain from intervening, respondents reported 3 key elements that need to be confirmed in future research and that may have implications for future work on bullying prevention. These included: first, the potential importance of clear communication to children that adults expect bystanders to intervene when witnessing bullying; second, the potential of direct education about how bystanders can intervene to increase children's self-efficacy as defenders of those who are victims of bullying; and third, the assumption that it may be effective to encourage children's belief that bullying is morally wrong.

Medical Evaluation and Triage of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA Medical Evaluation Workgroup

Abstract: Numerous medical and psychiatric conditions can cause agitation; some of these causes are life threatening. It is important to be able to differentiate between medical and nonmedical causes of agitation so that patients can receive appropriate and timely treatment. This article aims to educate all clinicians in nonmedical settings, such as mental health clinics, and medical settings on the differing levels of severity in agitation, basic triage, use of de-escalation, and factors, symptoms, and signs in determining whether a medical etiology is likely. Lastly, this article focuses on the medical workup of agitation when a medical etiology is suspected or when etiology is unclear.

Overview of Project BETA: Best practices in Evaluation and Treatment of Agitation

Abstract: Agitation in emergency settings is a major concern, with a staggering 1.7 million episodes annually in the United States alone.1 Agitated individuals are at risk of becoming aggressive and violent, and of causing harm to themselves, others, and property. Agitation is a leading cause of hospital staff injuries and can cause untold physical and psychological suffering for patients and all those nearby.2–4 Yet, despite the pervasiveness of agitation, there is surprising inconsistency in treatment approaches, which can vary widely by region and institution. Many facilities now use techniques such as intervention teams, which are paged instantly when there is an agitated patient, or “management of assaultive behavior” protocols that seek to engage patients into voluntarily accepting treatment. However, far too many agencies still treat all episodes of agitation in a fashion that might best be described as “restrain and sedate.” Although regulatory agencies and advocacy groups have called for a reduction in the use of restraint and less coercion in psychiatric treatment, there has been inadequate discussion regarding effective, alternative management of the agitated patient. Clearly, a void has existed in quality guidelines for the treatment of agitation. To help address this need, the American Association for Emergency Psychiatry (AAEP), in October 2010, embarked on Project BETA (Best practices in Evaluation and Treatment of Agitation). Recruiting dozens of emergency psychiatrists, emergency medicine physicians, and others associated with acute care of the mentally ill, Project BETA has intended to provide guidelines that are not only effective and safety minded but also in the best interests of the patient. Creating quality guidelines for agitation is no easy task. Unlike most disease states, the research database on agitation is quite limited. Much of this can be ascribed to the difficulty in obtaining the informed consent necessary for most clinical studies. How does one get informed consent from a combative, threatening individual? Further, in those studies that do involve informed consent, questions might arise as to the severity of subjects' levels of agitation, if indeed they were even able to comply with the consent process. Given these obstacles, the Project BETA team determined that the best guidelines would be ascertained through a synthesis of the best available research with the expert consensus of seasoned clinicians. Until now, existent guidelines for agitation have focused solely on medication strategies. Yet, agitation can result from myriad origins, and its treatment is multifaceted, with pharmacology only playing 1 part. The Project BETA members recognized that to truly address the agitation spectrum, for the first time, guidelines should be developed that would direct clinicians in all interventional aspects, including triage, diagnosis, and verbal de-escalation, as well as medicine choices. Thus, 5 study workgroups were developed by using the basic approaches of emergency psychiatry as a foundation. The treatment goals of emergency psychiatry are as follows: (1) exclude medical etiologies for symptoms; (2) rapid stabilization of the acute crisis; (3) avoid coercion; (4) treat in the least restrictive setting; (5) form a therapeutic alliance; and (6) appropriate disposition and after-care plan.5 The 5 workgroups, projected in the order of following a patient through an intervention, were established to address the following topics: • Medical evaluation and triage of the agitated patient • Psychiatric evaluation of the agitated patient • Verbal de-escalation of the agitated patient • Psychopharmacologic approaches to agitation • Use and avoidance of seclusion and restraint Each group then created a written article and guidelines derived from evidence-based research and consensus outcome, which follow in this issue of Western Journal of Emergency Medicine. Although each article is able to stand on its own, the entire group is intended to be read and used collectively, as the articles are intertwined, referring to and leading into each other. Working with an agitated patient can be challenging, and, as in managing other medical emergencies, it requires both knowledge and skills. As in advanced cardiovascular life support training, the former can be learned in the classroom, but the latter requires practice. An important first step is learning to balance how to evaluate and manage the patient simultaneously. Medical assessment is essential to rule out life-threatening causes of agitation; yet, the patient who is agitated may not be cooperative with the evaluation. Thus, one's observation of the patient and medical judgment must drive decisions while engaging the patient in verbal de-escalation to obtain cooperation. Some patients with agitation can be de-escalated to calmness by verbal de-escalation alone. However, others will require medication, and the preferred medication should be one that targets the underlying etiology.6 Therefore, there is a need to establish a working diagnosis before instituting appropriate pharmacologic intervention. Mastering verbal de-escalation will result in many positive rewards for the clinician. Although some might believe that in their busy clinic there is no time to attempt de-escalation and restraining a patient is the speediest solution, it can indeed be just the opposite. Verbal de-escalation can typically be quite effective in a relatively brief period, while placing a patient in restraints can require significant staff involvement—from the time needed to “take down” and restrain the patient to the obligation for one-to-one observation. Throughput can be even more affected from a disposition standpoint, as many receiving facilities will not consider accepting a patient who has been recently restrained or a patient who is oversedated from injudicious use of medication. Avoiding the restraint process altogether can have safety and long-term implications. Perhaps as many as two thirds of staff injuries involving psychiatric patients occur during “containment” procedures for restraint.7 Furthermore, patients who have not been restrained and forcibly medicated during an emergency department visit will be less likely to mistrust and fear medical personnel and, thus, may feel more comfortable seeking assistance in the future, hopefully before reaching a highly agitated state. The authors of Project BETA understand that not all of the guidelines can be followed in every situation and have endeavored to make accommodations for that. The algorithms included in the articles provide guidance for noncoercive evaluation and management of the agitated patient, but allow for direct implementation of more restrictive interventions for those unfortunate patients who are so combative or delirious that other options would not be practical. Still, it is hoped that these guidelines will assist clinicians in recognizing that agitated individuals need not necessarily go straight into restraints but instead can be treated in a more benign, collaborative fashion, which will lead to less injuries, better therapeutic alliance, improved throughput and superior long-term outcomes.

Temperature and Violent Crime in Dallas, Texas: Relationships and Implications of Climate Change

Abstract: Introduction: To investigate relationships between ambient temperatures and violent crimes to determine whether those relationships are consistent across different crime categories and whether they are best described as increasing linear functions, or as curvilinear functions that decrease beyond some temperature threshold. A secondary objective was to consider the implications of the observed relationships for injuries and deaths from violent crimes in the context of a warming climate. To address these questions, we examined the relationship between daily ambient temperatures and daily incidents of violent crime in Dallas, Texas from 1993–1999. Methods: We analyzed the relationships between daily fluctuations in ambient temperature, other meteorological and temporal variables, and rates of daily violent crime using time series piece-wise regression and plots of daily data. Violent crimes, including aggravated assault, homicide, and sexualassault, were analyzed. Results: We found that daily mean ambient temperature is related in a curvilinear fashion to daily rates of violent crime with a positive and increasing relationship between temperature and aggravated crime that moderates beyond temperatures of 80 F and then turns negative beyond 90 F. Conclusion: While some have characterized the relationship between temperature and violent crime as a continually increasing linear function, leaving open the possibility that aggravated crime will increase in a warmer climate, we conclude that the relationship in Dallas is not linear, but moderatesand turns negative at high ambient temperatures. We posit that higher temperatures may encourage people to seek shelter in cooler indoor spaces, and that street crime and other crimes of opportunity are subsequently decreased. This finding suggests that the higher ambient temperatures expected with climate change may result in marginal shifts in violent crime in the short term, but are not likely to be accompanied by markedly higher rates of violent crime and associated increased incidence of injuryand death. Additional studies are indicated, across cities at varying latitudes that experience a range of daily ambient temperatures. [West J Emerg Med. 2012;13(3):239–246.]

Intimate Partner Violence and Social Pressure among Gay Men in Six Countries

Abstract: Author(s): Finneran, Catherine; Chard, Anna; Sineath, Craig; Sullivan, Patrick; Stepheneon, Rob | Abstract: Introduction: Recent research suggests that men who have sex with men (MSM) experience intimate partner violence (IPV) at significantly higher rates than heterosexual men. Few studies, however, have investigated implications of heterosexist social pressures – namely, homophobic discrimination, internalized homophobia, and heterosexism– on risk for IPV among MSM, and no previous studies have examined cross-national variations in the relationship between IPV and social pressure. This paperexamines reporting of IPV and associations with social pressure among a sample of internet-recruited MSM in the United States (U.S.), Canada, Australia, the United Kingdom, South Africa, and Brazil.Methods: We recruited internet-using MSM from 6 countries through selective banner advertisements placed on Facebook. Eligibility criteria were men age over 18 reporting sex with a man in the past year. Of the 2,771 eligible respondents, 2,368 had complete data and were included in the analysis. Threeoutcomes were examined: reporting recent experience of physical violence, sexual violence, and recent perpetration of physical violence. The analysis focused on associations between reporting of IPV and experiences of homophobic discrimination, internalized homophobia, and heteronormativity.Results: Reporting of experiencing physical IPV ranged from 5.75% in the U.S. to 11.75% in South Africa, while experiencing sexual violence was less commonly reported and ranged from 2.54% in Australia to 4.52% in the U.S. Perpetration of physical violence ranged from 2.47% in the U.S. to 5.76% in South Africa. Experiences of homophobic discrimination, internalized homophobia, and heteronormativity were found to increase odds of reporting IPV in all countries.Conclusion: There has been little data on IPV among MSM, particularly MSM living in low- and middleincome countries. Despite the lack of consensus in demographic correlates of violence reporting, heterosexist social pressures were found to significantly increase odds of reporting IPV in all countries.These findings show the universality of violence reporting amongMSMacross countries, and highlight the unique role of heteronormativity asa risk factor for violence reporting among MSM. The results demonstrate that using internet-based surveys to reachMSMis feasible for certain areas, although modified effortsmay be required to reach diverse samples of MSM. [West J Emerg Med. 2012;13(3):260–271.]

Psychiatric evaluation of the agitated patient: consensus statement of the american association for emergency psychiatry project Beta psychiatric evaluation workgroup.

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Emergency department visits for traumatic brain injury in older adults in the United States: 2006-08.

Abstract: INTRODUCTION: Traumatic brain injury (TBI) can be complicated among older adults due to age-related frailty, a greater prevalence of chronic conditions and the use of anticoagulants. We conducted this study using the latest available, nationally-representative emergency department (ED) data to characterize visits for TBI among older adults. METHODS: We used the 2006-2008 National Hospital Ambulatory Medical Care - Emergency Department (NHAMCS-ED) data to examine ED visits for TBI among older adults. Population-level estimates of triage immediacy, receipt of a head computed tomography (CT) and/or head magnetic resonance imaging (MRI), and hospital admission by type were used to characterize 1,561 sample visits, stratified by age Language: en

Serious Violence Victimization and Perpetration among Youth Living in the Slums of Kampala, Uganda

Abstract: Introduction: Violence among youth is a major public health issue globally Despite these concerns, youth violence surveillance and prevention research are either scarce or non-existent, particularly in developing regions, such as sub-Saharan Africa The purpose of this study is to quantitatively determine the prevalence of violence involving weapons in a convenience sample of service-seeking youth in Kampala Moreover, the study will seek to determine the overlap between violence victimization and perpetration among these youth and the potentially shared risk factors for these experiences Methods: We conducted this study of youth in May and June of 2011 to quantify and describe high-risk behaviors and exposures in a convenience sample (N¼457) of urban youth, 14–24 years of age, living on the streets or in the slums and who were participating in a Uganda Youth Development Link drop-in center for disadvantaged street youth We computed bivariate and multivariate logistic regression analyses to determine associations between psychosocial factors and violence victimization and perpetration Results: The overall prevalence of reporting violence victimization involving a weapon was 36%, and violence perpetration with a weapon was 19% In terms of the overlap between victimization and perpetration, 166% of youth (116% of boys and 241% of girls) reported both In multivariate analyses, parental neglect due to alcohol use (AdjOR¼228;95%CI: 112—462) and sadness (AdjOR¼436 ;95%CI: 181—1053) were the statistically significant correlates of victimization only Reporting hunger (AdjOR¼287 ;95%CI:130—633), any drunkenness (AdjOR¼235 ;95%CI:112—492) and any drug use (AdjOR¼302 ;95%CI:116—782) were significantly associated with both perpetration and victimization Conclusion: The findings underscore the differential experiences associated with victimization and perpetration of violence involving weapons among these vulnerable youth In particular, reporting hunger, drunkenness and drug use were specifically associated with victimization and perpetration These are all modifiable risk factors that can be prevented It is clear that these vulnerable youth are in need of additional services and guidance to ameliorate their adverse childhood experiences, current health risk behaviors and disadvantaged living context [West J Emerg Med 2012;13(3):253–259]

Current Trends in the Management of Difficult Urinary Catheterizations

Abstract: Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Repeated and unsuccessful attempts at urinary catheterization induce stress and pain for the patient, injury to the urethra, potential urethral stricture requiring surgical reconstruction, and problematic subsequent catheterization. Improper insertion of catheters also can significantly increase healthcare costs due to added days of hospitalization, increased interventions, and increased complexity of follow-up evaluations. Improved techniques for catheter placement are essential for all healthcare personnel involved in the management of the patient with acute urinary retention, including attending emergency physicians who often are the first physicians to encounter such patients. Best practice methods for blind catheter placement are summarized in this review. In addition, for progressive clinical practice, an algorithm for the management of difficult urinary catheterizations that incorporates technology enabling direct visualization of the urethra during catheter insertion is presented. This algorithm will aid healthcare personnel in decision making and has the potential to improve quality of care of patients.

Radiation Dose From Medical Imaging: A Primer for Emergency Physicians

Abstract: uciem_westjem_6804 Abstract: Introduction: Medical imaging now accounts for most of the US population's exposure to ionizing radiation. A substantial proportion of this medical imaging is ordered in the emergency setting. We aim to provide a general overview of radiation dose from medical imaging with a focus on computed tomography, as well as a literature review of recent efforts to decrease unnecessary radiation exposure to patients in the emergency department setting. Methods: We conducted a literature review through calendar year 2010 for all published articles pertaining to the emergency department and radiation exposure. Results: The benefits of imaging usually outweigh the risks of eventual radiation-induced cancer in most clinical scenarios encountered by emergency physicians. However, our literature review

Emergency department management of delirium in the elderly.

Abstract: An increasing number of elderly patients are presenting to the emergency department. Numerous studies have observed that emergency physicians often fail to identify and diagnose delirium in the elderly. These studies also suggest that even when emergency physicians recognized delirium, they still may not have fully appreciated the import of the diagnosis. Delirium is not a normal manifestation of aging and, often, is the only sign of a serious underlying medical condition. This article will review the significance, definition, and principal features of delirium so that emergency physicians may better appreciate, recognize, evaluate, and manage delirium in the elderly.

Feifel et al reply to Hays et al regarding The psychopharmacology of agitation: consensus statement of the American association for emergency psychiatry project BETA psychopharmacology workgroup.

Abstract: Author(s): Feifel, David; Wilson, Michael P; Pepper, David; Currier, Glenn W; Holloman, Garland

How long are patients willing to wait in the emergency department before leaving without being seen

Abstract: Introduction: Our goal was to evaluate patients’ threshold for waiting in an emergency department(ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness towait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status. Methods: We conducted this survey-based study from March to July 2010 at an urban academicmedical center. After triage, patients were given a multiple-choice questionnaire, designed toascertain how long they would wait for medical care. We collected data including age, gender, race,insurance status, and triage acuity level. We looked at the association between willingness to waitand these variables, using stratified analysis and logistic regression. Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventyone(51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and110 (32%) would wait indefinitely. No association was found between willingness to wait and race,gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended tobe older than 25, have higher acuity, and prefer the study site ED. Conclusion: Many patients have a defined, limited period that they are willing to wait for emergencycare. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED withoutbeing seen. This result suggests that efforts to reduce the percentage of patients who LWBS mustfactor in time limits. [West J Emerg Med. 2012;13(6):463-467]

Trajectories of Intimate Partner Violence Victimization

Abstract: Results: A 5-trajectory model best fit the data both statistically and in terms of interpretability. The trajectories across time were interpreted as low or no IPV, low to moderate IPV, moderate to low IPV, high to moderate IPV, and high and increasing IPV, respectively. Negative childhood experiences differentiated trajectory membership, somewhat, with childhood sexual abuse as a consistent predictor of membership in elevated IPV trajectories. Conclusion: Our analyses show how IPV risk changes over time and in different ways. These differential patterns of IPV suggest the need for prevention strategies tailored for women that consider victimization experiences in childhood and early adulthood. [West J Emerg Med. 2012;13(3):272–277.]

Subdural empyema presenting with seizure, confusion, and focal weakness.

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

Impact of the mental healthcare delivery system on california emergency departments.

Abstract: Introduction: This is an observational study of emergency departments (ED) in California to identify factors related to the magnitude of ED utilization by patients with mental health needs.Methods: In 2010, an online survey was administered to ED directors in California querying them about factors related to the evaluation, timeliness to appropriate psychiatric treatment, and disposition of patients presenting to EDs with psychiatric complaints.Results: One hundred twenty-three ED directors from 42 of California’s 58 counties responded to the survey. The mean number of hours it took for psychiatric evaluations to be completed in the ED, from the time referral was placed to completed evaluation, was 5.97 hours (95% confidence interval [CI], 4.82–7.13). The average wait time for adult patients with a primary psychiatric diagnosis in the ED, once the decision to admit was made until placement into an inpatient psychiatric bed or transfer to an appropriate level of care, was 10.05 hours (95% CI, 8.69–11.52). The average wait time for pediatric patients with a primary psychiatric diagnosis was 12.97 hours (95% CI, 11.16–14.77). The most common reason reported for extended ED stays for this patient population was lack of inpatient psychiatric beds.Conclusion: The extraordinary wait times for patients with mental illness in the ED, as well as the lack of resources available to EDs for effectively treating and appropriately placing these patients, indicate the existence of a mental health system in California that prevents patients in acute need of psychiatric treatment from getting it at the right time, in the right place. [West J Emerg Med. 2012;13(1):51–56.]

Visual Hallucinations: Charles Bonnet Syndrome

Abstract: The following is a case of Charles Bonnet syndrome in an 86-year-old woman who presented with visual hallucinations. The differential diagnosis of visual hallucinations is broad and emergency physicians should be knowledgeable of the possible etiologies.

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

Abstract: Introduction: Several factors influence the final placement of a medical student candidate on anemergency medicine (EM) residency program’s rank order list, including EM grade, standardized letterof recommendation, medical school class rank, and US Medical License Examination (USMLE) scores.We sought to determine the correlation of these parameters with a candidate’s final rank on a residencyprogram’s rank order list. Methods: We used a retrospective cohort design to examine 129 candidate packets from an EMresidency program. Class ranks were assessed according to the instructions provided by the students’medical schools. EM grades were scored from 1 (honors) to 5 (fail). Global assessments noted on the standardized letter of recommendation (SLOR) were scored from 1 (outstanding) to 4 (good). USMLEscores were reported as the candidate’s 3-digit scores. Spearman’s rank correlation coefficient wasused to analyze data. Results: Electronic Residency Application Service packets for 127/129 (98.4%) candidates wereexamined. The following parameters correlated positively with a candidate’s final placement on therank order list: EM grade, q¼0.379, P , 0.001; global assessment, q¼0.332, P , 0.001; and classrank, q¼0.234, P¼0.035. We found a negative correlation between final placement on the rank orderlist with both USMLE step 1 scores, q¼0.253, P¼0.006; and USMLE step 2 scores, q¼0.348, P¼0.004. Conclusion: Higher scores on EM rotations, medical school class ranks, and SLOR globalassessments correlated with higher placements on a rank order list, whereas candidates with higherUSMLE scores had lower placements on a rank order list. However, none of the parameters examined correlated strongly with ultimate position of a candidate on the rank list, which underscores that otherfactors may influence a candidate’s final ranking. [West J Emerg Med. 2012;13(6):458–462.]

Bath salts: the ivory wave of trouble.

Abstract: Mephedrone and MDPV are both β-ketophenethylamine derivatives of cathinone, a compound isolated from the East African plant Catha edulis (khat, qat). Mephedrone is commonly referred to as plant food, MCAT, 4-MMC, meow meow, meph, and drone; MDPV is commonly called MTV, MDPK, Magic, and Super Coke. Both are structurally similar to amphetamines, with mephedrone sharing close similarities with methamphetamine and MDPV with ecstasy (3,4-methylenedioxymethamphetamine; MDMA). Bath salts pose an increasing public health risk in the United States, with reports of toxicity and mortality increasing along with calls to poison centers throughout the United States. Packages labeled with innocuous monikers such as White Ice, Ivory Wave, Ocean Snow, Lunar Wave, and Vanilla Sky intentionally belie the dangerous substances within, which are by no means intended to replace legitimate bath products. The white or tan crystalline powder commonly is administered by nasal insufflation or oral ingestion; however, rectal suppository and less commonly, intramuscular or intravenous injection, are also reported.1,2 A movement to ban these substances is growing in the United States, following similar actions in Europe.3 Although successfully outlawed in some locales, this movement has not eliminated the public health hazards posed by mephedrone or MDPV. Emergency physicians (EP) should thus be knowledgeable in the epidemiology of bath salt abuse, the clinical toxidrome with which bath salt toxicity presents, and appropriate treatment strategies to reduce morbidity and mortality in patients presenting with bath salt toxicity.

Time series analysis of emergency department length of stay per 8-hour shift.

Abstract: Author(s): Rathlev, Niels K.; Obendorfer, Daniel; White, Laura F.; Rebholz, Casey M.; Magauran, Brendan; Baker, Willie; Ulrich, Andrew; Fisher, Linda; Olshaker, Jonathan | Abstract: Introduction: The mean emergency department (ED) length of stay (LOS) is considered a measure of crowding. This paper measures the association between LOS and factors that potentially contribute to LOS measured over consecutive shifts in the ED: shift 1 (7:00 AM to 3:00 PM), shift 2 (3:00 PM to 11:00PM), and shift 3 (11:00 PM to 7:00 AM).Methods: Setting: University, inner-city teaching hospital. Patients: 91,643 adult ED patients between October 12, 2005 and April 30, 2007. Design: For each shift, we measured the numbers of (1) ED nurses on duty, (2) discharges, (3) discharges on the previous shift, (4) resuscitation cases, (5) admissions, (6) intensive care unit (ICU) admissions, and (7) LOS on the previous shift. For each 24-hour period, we measured the (1) number of elective surgical admissions and (2) hospital occupancy. We used autoregressive integrated moving average time series analysis to retrospectively measure the association between LOS and the covariates.Results: For all 3 shifts, LOS in minutes increased by 1.08 (95% confidence interval 0.68, 1.50) forevery additional 1% increase in hospital occupancy. For every additional admission from the ED, LOS in minutes increased by 3.88 (2.81, 4.95) on shift 1, 2.88 (1.54, 3.14) on shift 2, and 4.91 (2.29, 7.53) onshift 3. LOS in minutes increased 14.27 (2.01, 26.52) when 3 or more patients were admitted to the ICU on shift 1. The numbers of nurses, ED discharges on the previous shift, resuscitation cases, andelective surgical admissions were not associated with LOS on any shift.Conclusion: Key factors associated with LOS include hospital occupancy and the number of hospital admissions that originate in the ED. This particularly applies to ED patients who are admitted to the ICU. [West J Emerg Med. 2012;13(2):163–168.]

Emergency Physician Estimation of Blood Loss

Abstract: Introduction Emergency physicians (EP) frequently estimate blood loss, which can have implications for clinical care. The objectives of this study were to examine EP accuracy in estimating blood loss on different surfaces and compare attending physician and resident performance.

Therapy Dogs in the Emergency Department

Abstract: Introduction: This study examined acceptance by staff and patients of a therapy dog (TD) in the emergency department (ED). Methods: Immediately after TD visits to a University Hospital ED, all available ED staff, patients, and their visitors were invited to complete a survey. Results: Of 125 ‘‘patient’’ and 105 staff responses, most were favorable. Ninety-three percent of patients and 95% of staff agreed that TDs should visit EDs; 87.8% of patients and 92% of staff approved of TDs …

Race, Ethnicity, Substance Use, and Unwanted Sexual Intercourse among Adolescent Females in the United States

Abstract: sexual intercourse against one’s will, and the effect of substance use on these disparities. Methods: We analyzed data from adolescent women participating in the Youth Risk Behavior Survey. Bivariate associations and logistic regression models were assessed to examine associations among race/ethnicity, forced sex, and substance use behaviors. Results: Being forced to have intercourse against one’s will and substance use behaviors differed by race/ethnicity. African Americans had the highest prevalence of having been forced to have sexual intercourse (11.2%). Hispanic adolescent women were the most likely to drink (76.1%), Caucasians to binge drink (28.2%), and African Americans to use drugs (44.3%). When forced sexual intercourse was regressed onto both race/ethnicity and substance use behaviors, only substance use behaviors were significantly associated with forced sexual intercourse. Conclusion: Differences in substance use behaviors account for the racial/ethnic differences in the likelihood of forced sexual intercourse. Future studies should explore the cultural and other roots of the racial/ethnic differences in substance use behavior as a step toward developing targeted interventions to prevent unwanted sexual experiences. [West J Emerg Med. 2012;13(3):283–288.]

The Ottawa knee rule: examining use in an academic emergency department.

Abstract: Introduction: The Ottawa Knee Rule is a validated clinical decision rule for determining whether knee radiographs should be obtained in the setting of acute knee trauma. The objectives of this study were to assess physician knowledge of, barriers to implementation of, and compliance with the Ottawa Knee Rule in academic emergency departments (EDs), and evaluate whether patient characteristics predict guideline noncompliance. Methods: A 10 question online survey was distributed to all attending ED physicians working at three affiliated academic EDs to assess knowledge, attitudes and self-reported practice behaviors

Cervical ectopic pregnancy.

Abstract: A 31-year-old, who is gravida 2 para 1 at 6 weeks by last menstrual period, presents for vaginal bleeding starting approximately 5 days earlier. The bleeding was initially light, and there was no associated abdominal pain. The bleeding seemed to stop when she laid down and increased upon standing. Past medical, surgical, and social histories were unremarkable. On exam, vital signs were normal. Pelvic exam showed blood at the external orifice of the uterus, no cervical motion tenderness or adenexal tenderness. The remainder of the exam was unremarkable. Quantitative serum human chorionic gonadotropin was 7,470. Transabdominal and transvaginal bedside ultrasounds are shown in Figures 1 and ​and2,2, demonstrating an hour-glass deformity of the cervix. Fetal heart tones were present. The findings are consistent with cervical ectopic pregnancy. Figure 1 Transabdominal ultrasound in longitudinal plane. Figure 2 Transvaginal ultrasound in longitudinal plane.

An Uncommon Case of Abdominal Pain: Superior Mesenteric Artery Syndrome

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

Diplopia from subacute bilateral subdural hematoma after spinal anesthesia.

Abstract: Subdural hematoma (SDH) is a rare, but life-threatening complication of spinal anesthesia. Subdural hematoma resulting from this procedure could present with vague symptoms such as chronic headache and could easily be missed. Chronic headache is one of the symptoms of chronic SDH in postpartum women. Diplopia as the presenting complaint in SDH secondary to peripartum spinal anesthesia has not, to our knowledge, been previously reported. Here, we report a case of diplopia secondary to postpartum subacute bilateral SDHs with transtentorial herniation after spinal anesthesia in a healthy primagravid 25-year-old woman. SDH can expand gradually and the initial symptoms might be subtle as in our case, despite critically high intracranial pressure.