Journal of Emergencies, Trauma, and Shock
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Year : 2011  |  Volume : 4  |  Issue : 3  |  Page : 441-445

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Date of Web Publication16-Aug-2011

How to cite this article:
. Abstract. J Emerg Trauma Shock 2011;4:441-5

How to cite this URL:
. Abstract. J Emerg Trauma Shock [serial online] 2011 [cited 2021 May 13];4:441-5. Available from:

INDO-US Emergency & Trauma Collaborative

Advancing Academic Acute Medicine By Education & Research

TeamHealth INDO-US Grant Award for Global Emergency Medical Sciences 2010

TeamHealth supported 12 emergency medicine residents' presentation of their research at the INDO-US Emergency Medicine Summit 2010 at Vadodara, Gujarat, India, from October 6 to October 10, 2010.

2010 INDO US TeamHealth Grant Recipients

IV tPA use for acute ischemic stroke in an inner city community hospital

Rose Baron, Wes Eilbert

Department of Emergency Medicine, University of Illinois at Chicago Emergency Medicine Program, Chicago, Illinois, USA

Background : tPA use for ischemic stroke received FDA approval in 1996, though concern has been raised about its use outside of university centers. While some studies have established the safety of tPA given in a community setting, data regarding its use in inner city hospitals are limited. Materials and Methods : This is a retrospective case series of all patients receiving tPA for ischemic stroke in an urban non-university hospital in Chicago, Illinois, since 2005. Results : 23 patients received tPA during the study period. The mean age was 69 years with 60% being males. The mean time from symptom onset to ER presentation was 61 minutes. The average time from ER presentation to tPA administration was 78 minutes. Two protocol violations occurred, both due to elevated blood pressure, but neither had a tPA-related complication. Five patients (22%) suffered a tPA-related complication, three of which (13%) were cerebral hemorrhages of which one was asymptomatic. This is a cerebral hemorrhage rate approximately double that reported in the original study of tPA use for ischemic stroke. Two patients died, neither was due to a hemorrhagic complication. The median NIHSS at presentation and at 24 hours were 14 and 6, respectively. Positive outcome (NIHSS improvement by 4 points) was seen in 11 patients (48%). Conclusion : tPA use in an inner city non-university hospital provided a positive outcome in a large percentage of patients with ischemic stroke, though increased risk in the cerebral hemorrhage may limit its usefulness.

Ambulatory care by disaster responders in the tent camps of Port-au-Prince, Haiti, January 2010

John Broach

Department of Emergency Medicine, Division of Disaster Medicine & Emergency Management, University of Massachusetts Medical School, UMass Memorial Medical Center, USA

On January 12, 2010, a magnitude 7.0 earthquake occurred approximately 10 miles west of Port-au-Prince, Haiti and this has created one of the worst humanitarian disasters in history. The purpose of this report is to describe the types of illness experienced by people living in tent camps around the city in the immediate aftermath of this event. The data were collected by a team of medical personnel working with an international NGO and operating in the tent camps surrounding the city from day 15 to day 18 following the earthquake. In agreement with existing literature describing patterns of illness in refugee and internally displaced populations, the authors note a preponderance of pediatric illness with 53% of cases being patients under 20 years of age and 25% under five years of age. The most common complaints noted, by category, were: respiratory (24.6%), gastrointestinal (16.9%), and genitourinary (10.9%). Another important feature of illness observed among this population was the high incidence of malnutrition among pediatric patients. This report should serve as a guide for future medical interventions in refugee and IDP situations and reinforces the need for strong nutrition support programs in disaster relief operations of this kind.

Unique incident command structure during hospital surge due to H1N1 pandemic influenza incident command response plan

Susan Cheng

Department of Emergency Medicine, State University of New York Downstate, NY Emergency Medicine Program, USA

SUNY Downstate Medical Center established a unique sustainable Incident Command protocol in order to respond effectively to the 2009 H1N1 pandemic influenza outbreak. The emergency operations center (EOC) would be activated in the event standard resources were overwhelmed and a rotating incident commander (IC) leads the EOC. The IC provides overall strategic direction for hospital incident management and support activities, including emergency response and recovery. The IC is randomly selected from a list of department leaders and mandated to be on call for 24 hours every 95 days (on site from 9 a.m. to 9 p.m., via phone from 9 p.m. to 9 a.m., and never farther than 30 minutes from the hospital). They had 24-hour access to a clinical advisor, who was a physician from either the departments of internal medicine, family medicine, or emergency medicine. The IC was required to attend two EOC general meetings every day (at 9 a.m. and 9 p.m.). The meeting at 9 a.m. established the official exchange of duties from one IC to the next and a review/update of the incident action plan. This unique rotating IC structure worked very well during the 2009 H1N1 pandemic influenza outbreak. Departmental leaders had an opportunity to practice assuming the very important role of IC. This structure was extremely agreeable to all participants, especially in light of the limited time that persons were asked to serve, as well as the benefits of decreased stress and fatigue that is normally faced by a sustained response.

The impact of implementing the single provider model of emergency medicine in a pediatric hospital

Brad Crosby

Department of Emergency Medicine, Wake Forest University, Winston-Salem, North Carolina, USA

Study Objective
: The Meyer Pediatric Hospital in Florence, Italy, recently implemented the single provider model of emergency medicine (EM). Prior to these changes, patients were triaged by a nurse to either a surgeon or pediatrician based on the presenting complaint. Our objective was to analyze the outcomes of patients seen by surgeons prior to this transformative change and compare it to the outcomes of those patients seen initially by emergency physicians (EPs). Materials and Methods : A retrospective, cohort study was undertaken to review the charts of patients seen in the Meyer ED from congruent periods between 2005 and 2008 for the three most common categories of problems seen by surgeons before the systems change: abdominal pain, minor head trauma, and testicular pain. Outcomes include misdiagnoses/complicated 72-hour return visits, sub-specialty consultation rates, dispositions (observation, admission or discharge home), radiologic imaging, urgent interventions and surgeries. Results : 2,415 patient visits are included for analysis. EPs saw more patients (1388 vs. 1027) and obtained more consultations (25.4% vs. 8.1%) than surgeons. When surgeons cared for patients primarily, patients were more likely to undergo urgent interventions (9.5% vs. 6.7%), surgery (8.0% vs. 4.9%), have more radiographic images in minor head trauma (13.6% vs. 7.4%) and more plain films for abdominal pain (3.1% vs. 1.3%). There is a trend toward fewer missed diagnoses by EPs than surgeons (0.3% vs. 0.9%), but this difference is not statistically significant. Conclusions : The single provider model of EM where EPs manage all patients presenting to the ED is a safe and efficient model of emergency medicine care.

Ultrasound evaluation of cranial and long bone fractures in a cadaver model

Gerald DeMers, Donald Bennett, Salvatore Migliore, Leslie Simon

Department of Emergency Medicine, Naval Medical Center San Diego, California, USA

Background : Bone has different acoustic impedance than soft tissue, thereby allowing visualization of the cortical disruption found in fractures. Ultrasound may have potential in trauma triage where radiographic imaging is not available in austere environments. Objectives : To determine if emergency physicians can accurately diagnose cranial and long bone fractures using ultrasound. Materials and Methods : Multicenter prospective double-blind pilot cadaveric study using high-frequency linear ultrasound was carried out. Cadavers had artificially induced fractures placed in two long bone sites (distal radius and proximal tibia) and two cranial sites (temporal parietal junction and frontal bone) with the contralateral side serving as a control. To avoid inter-user variability, a trained technician scanned the sites in controlled short and long axis views. After a standard orientation, residents and staff emergency physicians evaluated real-time images of the sonographic evaluation of each site and gave a fracture or no fracture response. Data were analyzed for sensitivity, specificity and accuracy. Regression analysis was performed to see if accuracy was associated with year of training. Results : Interim results for 61 sonographic evaluations varied per site and demonstrated combined sensitivity (90.1%), specificity (84.1%), and accuracy (87.1%) (P<0.001). Conclusions : Ultrasound can be utilized in the evaluation of cranial and long bone fractures. Further studies in patients with fractures will likely improve findings noted in this pilot study. This study had several limitations that may impact fracture detection to include lack of contralateral comparison, lack of soft tissue reactive changes of fractured sites, and tactile feedback (point of maximal tenderness). Edge artifact appearing as "pseudo-fracture" (fracture was not present but linear beam and round cortex were interpreted as disrupted cortex) may have impacted specificity.

A review of the combined response of kings county hospital center and SUNY downstate medical center to the threat of pandemic influenza A (H1N1) in April 2009

Jaime Edelstein

Department of Emergency Medicine, State University of New York Downstate, NY Emergency Medicine Program, USA

Background : Plans were made in adjacent high volume hospitals for expected burst in patient encounters. Leadership in the campaign created a task force that would regularly meet to re-evaluate strategy. Materials and Methods : The purpose of the planning committee was to design a fluid and sustainable response to the patient surge. Hospital staff and affiliates were kept up to date on current health department and CDC recommendations and educated on infection control and prevention. Internet was heavily utilized as a method of information dissemination. Provisions for community outreach, including education and vaccination for high-risk populations, were implemented. Roving programs in visible areas and POD stations were put in place to vaccinate staff. Supplemental staffing and expanded medical access opportunities were devised and placed into action during the first wave of the outbreak in anticipation of an overwhelming outbreak in the fall months. Results : Medical departments that were most taxed included the ER and walk-in clinics. The pediatric census nearly doubled, with influenza like illness representing more than 75% of the presenting complaints on some days. There were no H1N1 related fatalities reported. Conclusion : Containment of an epidemic requires a swift and coordinated effort by a hospital and public health network. The interplay of the community and the virus is unpredictable; surveillance and a dynamic response were paramount to this effort's overall success.

Use of point of care lactate in the prehospital aeromedical environment

Ryan Murray, Angela Talbot R N, Alexandra Sanseverino, Peter McCahill, Virginia Mangolds FNP-C, Jesse Volturo, Marc Restuccia, Chad Darling, Alison Schroth Hayward, Marie Mullen

Department of Emergency Medicine, University of Massachusetts Medical School, UMass Memorial Medical Center, USA

Background : Lactate measurement has been used to identify critical medical illness and initiate early treatment strategies. The prehospital environment offers an opportunity for very early identification of critical illness and commencement of care. We hypothesized that point of care lactate measurement in the prehospital aeromedical environment would (i) identify medical patients with high mortality risk, (ii) influence fluid, transfusion, and ventilator management, and (iii) increase early central venous catheter (CVC) placement. Materials and Methods : Critically ill, non-cardiac, non-trauma patients who were transported between 9/2007 and 3/2009 by UMass Memorial LifeFlight, a university-based emergency medical helicopter service, were eligible for enrollment. Patients were prospectively randomized to receive a fingerstick whole blood lactate measurement on an alternate day schedule. Flight crews were not blinded to results. Flight crews were asked to inform the receiving attending physician of the results. The primary endpoint was the ability of a high prehospital lactate value (>4 mmol/L) to identify mortality. Secondary endpoints included differences in post-transport fluid, transfusion, ventilator management and decrease in time to CVC placement. Categorical variables were compared between groups by Fisher's Exact Test, and continuous variables were compared by t-test. Results : Patients (n=59) were well matched for age and acuity. In the lactate cohort (n=20), mean lactate was 7΁1 mmol/L. Our interim analysis revealed that prehospital lactate levels of 4 mmol/L or greater did show a trend toward higher mortality (P=0.20) with an odds ratio of 3.33 [95% CI (0.5-21.6)]. Secondary endpoints did not show a statistically significant change in management between the lactate and non-lactate groups. There was a trend toward decreased time to post-transport CVC in the non-lactate faction. Conclusions : Prehospital point of care lactate levels greater than 4 mmol/L may help stratify risk of mortality. Further investigation is needed, as this was a limited study. Our analysis did not find a significant change in post-transport management.

Model for efficiency assessment of tiered health care systems throughout South Africa

Gabrielle A Jacquet, Lauren Whiteside 1 , Wrenn Levenberg 1 , David Richards

Department of Emergency Medicine, Denver Health Residency in Emergency Medicine, Denver, Colorado, 1 University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA

Background : The public health system in South Africa is a tiered system. Throughout the western cape are community health centers (CHCs) which serve as the entry point for the majority of patients seeking medical care. Patients who require urgent or emergent treatment at the CHCs are transferred to secondary hospitals for further care. Patients requiring the highest level of care, such as specialized radiology or sub-specialist care, are then transferred to a tertiary hospital. Our hypothesis was to study Addressable limitations of basic human and technical capacities lead to preventable transfers and treatment delays for patients seeking care in this system. Materials and Methods : Over a 6-week period in 2006, 272 charts from patients transferred from one of five CHCs to a secondary hospital were reviewed to uncover addressable human and technical limitations that may have led to transfer. Results : We found that if off-site radiology reads were made available or staff was better trained in radiograph interpretation, 28 transfers could have been avoided. If ultrasound were available on site, 14 transfers could have been prevented. If providers were trained to perform incision and drainage of simple abscesses, 10 transfers would have been eliminated. Conclusion : In summary, 19% (52/272) of transfers could have been avoided if specific resources or training were available to CHCs. The next step will be to compare the cost of providing these resources to the savings from decreased patient transfers. We believe the techniques used in this study can serve as a model for efficiency assessment of tiered health care systems throughout South Africa and beyond.

Direct laryngoscopy competency and proficiency perspectives through training

V Tucci, Lindsay Lyon, J Wilson

Department of Emergency Medicine, University of South Florida, Emergency Medicine Program, Tampa, Florida, USA

Introduction : Direct laryngoscopy intubation is a fundamental resuscitation skill in the field of emergency medicine. We wanted to gauge medical student perceptions regarding direct laryngoscopy and the number of endotracheal intubations that they perceived necessary for competence and for proficiency in comparison to the emergency medicine residency review committee's requirement of 35. Our hypothesis was that students exposed to emergency medicine through a formal clerkship would have a better understanding of the skill involved in laryngoscopy and their perceived numbers needed to achieve each skill level would be higher than their counterparts without such exposure. US allopathic medical students were invited to answer an online survey; the survey data tested our null hypothesis of no relationship between EM exposure through a formal clerkship and student perception of the number of intubations needed to achieve competence versus proficiency or expertise. A fisher exact test was used to look for significance. In conclusion, medical students exposed to EM clerkships were more likely to recognize the inherent difficulties of direct laryngoscopy and cite a higher number of intubations needed to be competent and proficient. Background : Direct laryngoscopy is the primary method of tracheal intubation and is a fundamental resuscitation skill. Competency is essential in the field of Emergency Medicine. This procedure is taught annually in the US to more than 330,000 persons. Even though it is considered a basic skill, the performance by novice intubators is poor; on average, initial trainees succeed in only 50% of attempts.2-5. We wanted to gauge medical student perceptions regarding their abilities with respect to direct laryngoscopy and the number of endotracheal intubations that they perceive are necessary for competence and for proficiency and compare these numbers to the emergency medicine residency review committee's requirement of 35. Our hypothesis was that students who were exposed to real world emergency medicine through a formal clerkship would have a better understanding of the skill involved in laryngoscopy and their numbers needed to achieve each skill level would be higher than their counterparts who have not had such exposure. Materials and Methods : US allopathic medical students were invited to answer an online survey regarding their experiences with direct laryngoscopy and endotracheal intubation and perceptions regarding competence and proficiency in advanced airway management. The survey data tested our null hypothesis of no relationship between EM exposure through a formal clerkship and student perception of the number of intubations needed to achieve competence versus proficiency or expertise. After calculating the mean number of perceived necessary intubations across all medical students, a Fisher Exact Test was used to look for significance of perceived number of intubations within the group of medical students that completed an EM clerkship compared to the overall mean at an alpha level of 0.05. In addition, the perceived number within the EM clerkship group was compared to the RRC requirement. Results : Medical students had varied responses with respect to competence and proficiency (e.g., 6-10 to 751-1000 intubations for competence and 21-30 to 751-1000 for expertise). There was no agreement between medical student classes or progression in numbers by year of study. The overall group of students thought a mean of 21-30 intubations was sufficient to become competent and believed 51-100 were necessary to be proficient. With respect to students who completed an EM clerkship, the odds ratio that the student would think they needed more intubations than the total mean number for both student groups combined was 2.06 with a 95%CI = 1.0014-4.2485 (P<0.05). Conclusions : Medical students exposed to EM clerkships were more likely to recognize the inherent difficulties of direct laryngoscopy and cite a higher number of intubations needed to be competent and proficient than the mean number offered by their peers who had not completed an EM clerkship. The mean believed to competent was below the EM Residency Review Committee requirement of 35; however, the mean perceived to be proficient was noted to be higher than the current recommendations.

Anatomical variation of internal jugular and femoral vein using ultrasound

Raymond Merritt

Department of Emergency Medicine, University of South Florida, Emergency Medicine Program, Tampa, Florida, USA

Introduction : Determination of anatomical variations of the internal jugular and femoral veins using ultrasound in the emergency department. This was a prospective, non-therapeutic, non-interventional, observational study using a convenience sample of patients in tampa general's adult emergency care center. Materials and Methods : Patients meeting the inclusion criteria were randomly approached and selected while waiting for their workup in the emergency department. Inclusion criteria were 18 years of age or older, speak English or Spanish, alert and oriented to person, place, time, situation with stable vital signs. Selected patients (n=100) were placed supine with head of bed elevation at 20°. Measurements were then obtained using Sonosite Micromaxx ultrasound with (probe size) and degree of head rotation measured by a goniometer at 0°, 45°, and 80°. Counterclockwise head rotation would constitute right-sided measurements and vice versa. All images were obtained with the transducer in transverse orientation. Then, the Micromaxx program calculated centimeter measurements. The angles were measured by hand using a goniometer on the ultrasound screen. The femoral vein measurements are described in the same fashion except the femur has an external rotation of 20° and 40°. Vessel size (anterior-posterior, longitudinal), distance between the vessels and any overlapping between them were measured in centimeters. Anatomical angles were measured in relation to the horizontal diameter in center of the carotid artery, with +0° to +180° de picting the vein above the artery and 0° to −180° below the artery. The data were then sorted by 45° increments and degree of head rotation. Other considerations such as body mass index (BMI), age, sex, and history of DVT/PE or any vessel trauma (history of central line insertions, penetrating trauma, surgeries/reconstructions) were noted. Results : The average age of the participants was 52.9 years, BMI was 28.1, males formed 49.5% and females formed 50.5%. 10.9% had history of DVT/PE and 16.8% had vessel trauma. Previous studies (NJEM) have shown that when the IJ is 46°-90° in relation to the CA (high-risk zone), using the "landmark technique " proved difficult to impossible for central line placement. After reviewing 100 patients, the data revealed that increasing neck rotation up to 80° in either direction (clockwise/counterclockwise) would anatomically place the IJ in this high-risk zone. Our study showed 24.2% of right IJ (P≤0.001) and 39% of left IJ (P≤0.001) as compared with the NJEM study showing 11% right IJ and 22% left IJ. Interestingly enough, a few patients in our study had an anatomical reversal with the IJ and CA. Conclusion : Our study correlates with the previous studies on this topic. Increasing head rotation will increase the possibly of complications during IJ cannulation with the "landmark technique". The Left IJ appears to have a higher degree of difficulty as compared to the right. Placing the head in neutral position, avoiding rotation, and using the ultrasound-guided method should be followed.

Cancer diagnosis and outcomes in Michigan emergency department versus other settings amongst the elderly

Veronica Sikka, Joseph P Ornato

Department of Emergency Medicine, Virginia Commonwealth University, Emergency Medicine Program, Richmond, Virginia, USA

Background : This study determined the incidence of colorectal and lung cancers diagnosed in EDs. The characteristics of these patients and the correlation between diagnosis in the ED, stage at diagnosis, and receipt of cancer treatment were also examined. Materials and Methods : A population-based sample of all Michigan cancer cases diagnosed in all EDs and other health care settings was used to extract a sample of patients >65 years old, diagnosed with colorectal and lung cancers between January 1, 1996 and June 30, 2000 (n=20,311). Logistic regressions were used for the statistical analysis. Results : Patients diagnosed with colorectal cancer in the ED were more likely insured by Medicaid prior to diagnosis, had an inpatient admission prior to diagnosis, had three or more comorbidities, and were more likely be aged 85 years and older. Patients who had at least one PCP visit prior to diagnosis were less likely to be diagnosed with colorectal and lung cancers in the ED. Patients diagnosed with lung cancer in the ED were more likely to have an inpatient admission prior to diagnosis, have a higher comorbidity burden, and be African-American and older (80+). Patients with an ED cancer diagnosis were more likely to be at later stages compared to patients diagnosed in other settings. Lung cancer diagnoses in the ED were associated with a decreased likelihood of resection and/or radiation. Conclusions : An examination of patients' patterns of care leading to an ED cancer diagnosis lends insight to the conditions precipitating a more acute diagnosis and their associated outcomes.

B-RIPPED-scan for evaluation of ED patients with shortness of breath

Hjalti M Bjornsson, Brian Campbell, David Evans, Virginia M Stewart, Valerie Baur, Barry J Knapp, Don Byars, William D Alley

Department of Emergency Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA

Background : Ultrasound guides emergency physicians in evaluating life-threatening illnesses. Validated ultrasound exams exist for independent assessment of congestive heart failure, pneumothorax, pulmonary embolism, intravascular volume, and cardiac function. The B-RIPPED ultrasound scan evaluates pulmonary B-lines, right ventricle size, inferior vena cava, pleural and pericardial effusion, pneumothorax, ejection fraction, and lower extremity deep venous thrombosis. Objectives : The B-RIPPED algorithm standardizes the evaluation of emergency department (ED) patients presenting with undifferentiated shortness of breath (SOB). Primary outcomes measured include the magnitude of change in differential diagnoses. Materials and Methods : This prospective study was performed on a convenience sample of patients (aged 18-89 years) presenting with undifferentiated SOB to an academic ED. Subjects were excluded if they had a known history of asthma. The treating ED physician, who ranked potential diagnoses, evaluated eligible patients. A study investigator performed the B-RIPPED scan and provided the initial treating physician with the results. The treating physician completed a second differential diagnosis ranking. Changes in the differential diagnosis ranking, physician orders, and interventions were compiled. This ongoing investigation aims for the enrollment of 200 patients from May 2010 to November 2011. Results : Of the 17 patients enrolled to date, clinical suspicion decreased for pericardial (64%) and pleural effusion (73%), pneumothorax (55%), pulmonary embolism (36%), congestive heart failure (45%), and anxiety (27%). Consideration increased for diabetic ketoacidosis (20%), intoxication/overdose (13%), and hypovolemia (7%). Conclusion : The B-RIPPED ultrasound algorithm is a valuable tool for the rapid evaluation and management of ED patients with SOB.

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