American Journal of Emergency Medicine, Jul 1, 2012
The aim of the study was to evaluate the risk of Friday the 13th on hospital admission rates and ... more The aim of the study was to evaluate the risk of Friday the 13th on hospital admission rates and emergency department (ED) visits. Methods: This was a retrospective chart review of all ED visits on Friday the 13th from November 13, 2002, to December 13, 2009, from 6 hospital-based EDs. Thirteen unlikely conditions were evaluated as well as total ED volumes. As a control, the Friday before and after and the month before and after were used. χ 2 Analysis and Wilcoxon rank sum tests were used for each variable, as appropriate. Results: A total of 49 094 patient encounters were evaluated. Average ED visits for Friday the 13th were not increased compared with the Friday before and after and the month before. However, compared with the month after, there were fewer ED visits on Friday the 13th (150.1 vs 134.7, P = .011). Of the 13 categories evaluated, only penetrating trauma was noted to have an increase risk associated with Friday the 13th (odds ratio, 1.65; 95% confidence interval, 1.04-2.61). No other category was noted to have an increase risk on Friday the 13th compared with the control dates. Conclusions: Although the fear of Friday the 13th may exist, there is no worry that an increase in volume occurs on Friday the 13th compared with the other days studies. Of 13 different conditions evaluated, only penetrating traumas were seen more often on Friday the 13th. For those providers who work in the ED, working on Friday the 13th should not be any different than any other day.
The Journal of Thoracic and Cardiovascular Surgery, 2004
See related editorial on page 10. Objective: Little was known about idiopathic laryngotracheal st... more See related editorial on page 10. Objective: Little was known about idiopathic laryngotracheal stenosis when it was first described. We have operated on 73 patients with idiopathic laryngotracheal stenosis, have confirmed its mode of presentation and response to surgical therapy, and have established long-term follow-up. Methods: Charts of 73 patients treated surgically for idiopathic laryngotracheal stenosis between 1971 and 2002 were retrospectively reviewed. Results: All patients were treated with a single-staged laryngotracheal resection, with (36/73) and without (37/73) a posterior membranous tracheal wall flap. Nearly all were women (71/73), with a mean age of 46 years (range, 13-74 years). Twenty-eight (38%) of 73 had undergone a previous procedure with laser, dilation, tracheostomy, T-tube, or laryngotracheal operations. After laryngotracheal resection, the majority of patients (67/73) were extubated in the operating room, and 7 required temporary tracheostomies, only 1 of whom was among the last 30 patients. All were successfully decannulated. There was no perioperative mortality. Principal morbidity was alteration of voice quality, which was mild and tended to improve with time. Sixty-seven (91%) of 73 patients had good to excellent long-term results with voice and breathing quality and do not require further intervention for their idiopathic laryngotracheal stenosis. Conclusion: Idiopathic laryngotracheal stenosis is an entity that occurs almost exclusively in women and is without a known cause. It is not a progressive process, but the timing of the operation is crucial. Single-staged laryngotracheal resection is successful in restoring the airway while preserving voice quality in more than 90% of patients. Protective tracheostomy is now rarely required (1/30). Long-term follow-up shows a stable airway and improvement in voice quality. I diopathic laryngotracheal stenosis (ILTS) is a rare disease characterized by an inflammatory cicatricial stenosis at the level of the cricoid and upper trachea. Patients experience dyspnea on exertion that progresses to dyspnea at rest, noisy breathing, stridor, or a combination of these symptoms. Symptoms develop over the course of months to years, with patients often given erroneous diagnoses and treated for asthma. It occurs almost exclusively in women in their third, fourth, and fifth decades who have no identifiable cause of airway stenosis. Its cause remains unknown. 1 Patients are considered to have ILTS if they have an inflammatory cicatricial stenosis of the subglottis, upper trachea, or both and known causes are excluded. Known causes of subglottic stenosis include post-intubation injury; airway trauma, including external injury; inhalational burns and irradiation; specific and nonspecific
Study Objective: Though select inpatient-based performance measures exist for the care of patient... more Study Objective: Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage (ICH), Emergency Departments (EDs) lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative (E-QUAL). Methods: We convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure (internal quality improvement [QI], benchmarking, or accountability) and examined data from E-QUAL-participating EDs to consider the validity and feasibility of proposed measures. The initially conceived set included 14 measure concepts of which 7 were selected for inclusion in the measure set after review of data and f...
Background Research suggests nonoccupational Post Exposure Prophylaxis (nPEP) is underprescribed ... more Background Research suggests nonoccupational Post Exposure Prophylaxis (nPEP) is underprescribed when indicated in the Emergency Department (ED). This study is an assessment of ED providers’ attitudes and practices regarding administration of HIV nPEP. Methods This was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED providers at work over a 4-month period from 5 hospital-based and 2 freestanding EDs with an annual census between 35,000 and 75,000 patients. The EDs are a combination of urban, suburban, and rural EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants. Results The majority of surveyed providers (133/149, 89.3%) believe it is their responsibility as an emergency provider to provide HIV nPEP in the emergency department (Figure 1). Although 91% (138/151) and 87% (132/151) of respondents are willing to prescribe nPEP to a patient in the ED for IV drug use and unprotected sex, respec...
ICU LOS was 23.0 days [IQR 12.8-37.0]. Five of the 18 (27.8%) died in hospital. The most frequent... more ICU LOS was 23.0 days [IQR 12.8-37.0]. Five of the 18 (27.8%) died in hospital. The most frequent pathogens were Staphylococcus aureus, Haemophilus influenza, oral flora, and Serratia marcescens. Conclusions: In this study, the incidence of VAP from patients intubated in the ED was low and not significantly different from patients intubated outside of the ED, suggesting that ED intubation may not present an increased risk for VAP. This study was limited by the small number of patients meeting the criteria for VAP. The few ED intubated patients who developed VAP had a high mortality. Further research is needed to assess the potential contribution of ED intubation on risk for VAP.
Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on p... more Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on preload dependence. The objectives of this study were to determine if a fluid responsiveness protocol would decrease progression of organ dysfunction, and a fluid responsiveness protocol would facilitate a more aggressive resuscitation. Methods: Prospective, 10-center, randomized interventional trial. Inclusion criteria: suspected sepsis and lactate 2.0 to 4.0 mmol/L. Exclusion criteria (abbreviated): systolic blood pressure more than 90 mmHg, and contraindication to aggressive fluid resuscitation. Intervention: fluid responsiveness protocol using Non-Invasive Cardiac Output Monitor (NICOM) to assess for fluid responsiveness (>10% increase in stroke volume in response to 5 mL/kg fluid bolus) with balance of a liter given in responsive patients. Control: standard clinical care. Outcomes: primary-change in Sepsis-related Organ Failure Assessment (SOFA) score at least 1 over 72 h; secondary-fluids administered. Trial was initially powered at 600 patients, but stopped early due to a change in sponsor's funding priorities. Results: Sixty-four patients were enrolled with 32 in the treatment arm. There were no significant differences between arms in age, comorbidities, baseline vital signs, or SOFA scores (P > 0.05 for all). Comparing treatment versus Standard of Care-there was no difference in proportion of increase in SOFA score of at least 1 point (30% vs. 33%) (note bene underpowered, P ¼ 1.0) or mean preprotocol fluids 1,050 mL (95% confidence interval [CI]: 786-1,314) vs. 1,031 mL (95% CI: 741-1,325) (P ¼ 0.93); however, treatment patients received more fluids during the protocol (2,633 mL [95% CI: 2,264-3,001] vs. 1,002 mL [95% CI: 707-1,298]) (P < 0.001). Conclusions: In this study of a ''preshock'' population, there was no change in progression of organ dysfunction with a fluid responsiveness protocol. A noninvasive fluid responsiveness protocol did facilitate delivery of an increased volume of fluid. Additional properly powered and enrolled outcomes studies are needed.
Journal of the American College of Emergency Physicians Open
Objectives: Most acute stroke research is conducted at academic and larger hospitals, which may d... more Objectives: Most acute stroke research is conducted at academic and larger hospitals, which may differ from many non-academic (ie, community) and smaller hospitals with respect to resources and consultant availability. We describe current emergency department (ED) and hospital-level stroke-related capabilities among a sample of community EDs participating in the Emergency Quality Network (E-QUAL) stroke collaborative. Methods: Among EQUAL participating EDs, we conducted a survey to collect data on ED and hospital stroke-related structural and process capabilities associated with quality of stroke care delivery and patient outcomes. EDs submitted data using a web-based submission portal. We present descriptive statistics of self-reported capabilities.
Journal of the American College of Emergency Physicians Open, 2021
Equity in the promotion of women and underrepresented minorities (URiM) is essential for the adva... more Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward‐thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM).
The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and f... more The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and fellowship training in the United States, recently revised the minimum standards for all training programs. These standards are codified and published as the Common Program Requirements. Recent specific revisions, particularly removing the requirement ensuring protected time for core faculty, are poised to have a substantial impact on emergency medicine training programs. A group of representatives and relevant stakeholders from national emergency medicine (EM) organizations was convened to assess the potential effects of these changes on core faculty and the training of emergency physicians. We reviewed the literature and results of surveys conducted by EM organizations to examine the role of core faculty protected time. Faculty nonclinical activities contribute greatly to the academic missions of EM training programs. Protected time and reduced clinical hours allow core faculty to engage in education and research, which are two of the three core pillars of academic EM. Loss of core faculty protected time is expected to have detrimental impacts on training programs and on EM generally. We provide consensus recommendations regarding EM core faculty clinical work hour limitations to maintain protected time for educational activities and scholarship and preserve the quality of academic EM. BACKGROUND T he Accreditation Council for Graduate Medical Education (ACGME) regulates residency and fellowship training in the United States by establishing minimum standards for accredited residency programs. The ACGME has developed, and periodically updates, the Common Program Requirements (CPRs) that apply to all ACGME accredited residencies. The CPRs
Journal of the American College of Radiology, 2019
Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients pres... more Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients presenting for treatment. Cervical spine injuries occur in 3% to 4% and thoracolumbar fractures in 4% to 7% of blunt trauma patients presenting to the emergency department. Clear, validated criteria exist for screening the cervical spine in blunt trauma. Screening criteria for cervical vascular injury and thoracolumbar spine injury have less validation and widespread acceptance compared with cervical spine screening. No validated criteria exist for screening of neurologic injuries in the setting of spine trauma. CT is preferred to radiographs for initial assessment of spine trauma. CT angiography and MR angiography are both acceptable in assessment for cervical vascular injury. MRI is preferred to CT myelography for assessing neurologic injury in the setting of spine trauma. MRI is usually appropriate when there is concern for ligament injury or in screening obtunded patients for cervical spine instability.
Procedure Appropriateness Category Relative Radiation Level Radiography chest Usually Appropriate... more Procedure Appropriateness Category Relative Radiation Level Radiography chest Usually Appropriate ☢ US chest May Be Appropriate O Radiography rib views Usually Not Appropriate ☢☢☢ MRI chest without and with IV contrast Usually Not Appropriate O MRI chest without IV contrast Usually Not Appropriate O Bone scan whole body Usually Not Appropriate ☢☢☢ CT chest with IV contrast Usually Not Appropriate ☢☢☢ CT chest without and with IV contrast Usually Not Appropriate ☢☢☢ CT chest without IV contrast Usually Not Appropriate ☢☢☢ FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢ WBC scan chest Usually Not Appropriate ☢☢☢☢
A 22-year-old male with sickle-cell trait presented with a 1-week history of progressive pain and... more A 22-year-old male with sickle-cell trait presented with a 1-week history of progressive pain and swelling in his left posterior thigh. He denied any trauma, fever, travel outside of the United States, or intravenous drug usage. On examination, he was afebrile at 36.8 °C (98.3 °F) with stable vital signs. His examination was significant for exquisite tenderness, erythema, induration, and swelling of the posterior thigh (Fig. 1). A computed tomography scan of the extremity was obtained that showed a 5.5cm × 4.4 cm × 20-cm fluid collection within the biceps femoris muscle (Fig. 2). The patient underwent open drainage of the abscess and was placed on linezolid. Wound and blood cultures were consistent with community-associated meth-icillin-resistant Staphylococcus aureus (ca-MRSA). Pyomyositis is an acute bacterial infection of the muscles characterized by subacute abscess formation. While pyo-myositis is rare in temperate climates, the incidence has been increasing, with the majority ...
Burnout is a complex syndrome thought to result from long‐term exposure to career‐related stresso... more Burnout is a complex syndrome thought to result from long‐term exposure to career‐related stressors. Physicians are at higher risk for burnout than the general United States (US) working population, and emergency medicine has some of the highest burnout rates of any medical specialty. Burnout impacts physicians’ quality of life, but it can also increase medical errors and negatively affect patient safety. Several studies have reported lower burnout rates and higher job satisfaction in academic medicine as compared with private practice. However, researchers have only begun to explore the factors that underlie this protective effect. This paper aims to review existing literature to identify specific aspects of academic practice in emergency medicine that may be associated with lower physician burnout rates and greater career satisfaction. Broadly, it appears that spending time in the area of emergency medicine one finds most meaningful has been associated with reduced physician burno...
Aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer are parts of a spec... more Aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer are parts of a spectrum of acute aortic syndromes that represent uncommon--but potentially deadly--diagnoses seen in the emergency department. The differential for acute aortic syndromes is large, as many conditions (including the much more common conditions of acute coronary syndromes and pulmonary embolism) present with many of the same chief complaints. This review looks at the features and classifications of acute aortic syndromes and presents evidence regarding the risk factors and chief complaints that can assist emergency clinicians in identifying the patients who require further investigation. Although no set of clinical factors has been shown to rule out aortic dissection, elements of a complete history and physical examination are critical in identifying patients who may be at risk for these diseases. In addition, the advantages and disadvantages of the various available advanced imaging strategi...
Journal of the American College of Emergency Physicians Open
A 48-year-old male presents with low back pain after falling off a ladder. He states he was climb... more A 48-year-old male presents with low back pain after falling off a ladder. He states he was climbing up a ladder when he slipped and fell on
Background: Left ventricular assist devices (LVADs) are used to treat patients with end-stage hea... more Background: Left ventricular assist devices (LVADs) are used to treat patients with end-stage heart failure, either as a bridge to heart transplantation or as destination therapy for patients not suitable for heart transplant. The number of patients with LVADs and the number of medical centers in the United States involved in implantation of these devices is increasing. Although the HeartWare Ventricular Assist Device (Medtronic) is currently the most common implant, based on previous popularity, there are still more HeartMate IIs (HMIIs) (Abbott Laboratories) currently in use. Given the high likelihood that a patient with an LVAD will seek ED care at some point, emergency physicians must be able to identify and manage the complications associated with these devices. The purpose of this study was to identify the type, frequency, and disposition of patients with an HMII LVAD who presented to an urban tertiary care referral center ED. Methods: This was a retrospective study of patients with an HMII LVAD who presented to an urban ED between April 1, 2009 and September 9, 2012. All patients with an HMII LVAD who presented to the ED were included in the study, and there were no exclusion criteria. Electronic medical records were reviewed by study investigators to identify all ED visits by HMII LVAD patients during the study period to identify the reason for presentation, the frequency of ED visits, and final patient disposition. Results: A total of 98 patients in the catchment area had an HMII LVAD implanted during the study period. Sixty-seven (68%) of these presented to the ED, for a total of 248 ED visits. The average number of ED visits per patient was 3.7. The most common reasons for presentation included bleeding (14.9%); volume overload (14.9%), weakness/lightheadedness/dizziness/syncope (9.6%), device malfunction (8.1%), and infection (2.8%). Approximately 56% of the ED visits were directly LVAD-related. Fifty-seven percent of the patients required admission to the hospital. Conclusions: Approximately two-thirds of patients with an HMII LVAD presented to the ED, many of whom presented multiple times. The most common complications observed were bleeding and volume overload. Fifty-seven percent of these patients required hospitalization.
Policy statements and clinical policies are the official policies of the American College of Emer... more Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.
American Journal of Emergency Medicine, Jul 1, 2012
The aim of the study was to evaluate the risk of Friday the 13th on hospital admission rates and ... more The aim of the study was to evaluate the risk of Friday the 13th on hospital admission rates and emergency department (ED) visits. Methods: This was a retrospective chart review of all ED visits on Friday the 13th from November 13, 2002, to December 13, 2009, from 6 hospital-based EDs. Thirteen unlikely conditions were evaluated as well as total ED volumes. As a control, the Friday before and after and the month before and after were used. χ 2 Analysis and Wilcoxon rank sum tests were used for each variable, as appropriate. Results: A total of 49 094 patient encounters were evaluated. Average ED visits for Friday the 13th were not increased compared with the Friday before and after and the month before. However, compared with the month after, there were fewer ED visits on Friday the 13th (150.1 vs 134.7, P = .011). Of the 13 categories evaluated, only penetrating trauma was noted to have an increase risk associated with Friday the 13th (odds ratio, 1.65; 95% confidence interval, 1.04-2.61). No other category was noted to have an increase risk on Friday the 13th compared with the control dates. Conclusions: Although the fear of Friday the 13th may exist, there is no worry that an increase in volume occurs on Friday the 13th compared with the other days studies. Of 13 different conditions evaluated, only penetrating traumas were seen more often on Friday the 13th. For those providers who work in the ED, working on Friday the 13th should not be any different than any other day.
The Journal of Thoracic and Cardiovascular Surgery, 2004
See related editorial on page 10. Objective: Little was known about idiopathic laryngotracheal st... more See related editorial on page 10. Objective: Little was known about idiopathic laryngotracheal stenosis when it was first described. We have operated on 73 patients with idiopathic laryngotracheal stenosis, have confirmed its mode of presentation and response to surgical therapy, and have established long-term follow-up. Methods: Charts of 73 patients treated surgically for idiopathic laryngotracheal stenosis between 1971 and 2002 were retrospectively reviewed. Results: All patients were treated with a single-staged laryngotracheal resection, with (36/73) and without (37/73) a posterior membranous tracheal wall flap. Nearly all were women (71/73), with a mean age of 46 years (range, 13-74 years). Twenty-eight (38%) of 73 had undergone a previous procedure with laser, dilation, tracheostomy, T-tube, or laryngotracheal operations. After laryngotracheal resection, the majority of patients (67/73) were extubated in the operating room, and 7 required temporary tracheostomies, only 1 of whom was among the last 30 patients. All were successfully decannulated. There was no perioperative mortality. Principal morbidity was alteration of voice quality, which was mild and tended to improve with time. Sixty-seven (91%) of 73 patients had good to excellent long-term results with voice and breathing quality and do not require further intervention for their idiopathic laryngotracheal stenosis. Conclusion: Idiopathic laryngotracheal stenosis is an entity that occurs almost exclusively in women and is without a known cause. It is not a progressive process, but the timing of the operation is crucial. Single-staged laryngotracheal resection is successful in restoring the airway while preserving voice quality in more than 90% of patients. Protective tracheostomy is now rarely required (1/30). Long-term follow-up shows a stable airway and improvement in voice quality. I diopathic laryngotracheal stenosis (ILTS) is a rare disease characterized by an inflammatory cicatricial stenosis at the level of the cricoid and upper trachea. Patients experience dyspnea on exertion that progresses to dyspnea at rest, noisy breathing, stridor, or a combination of these symptoms. Symptoms develop over the course of months to years, with patients often given erroneous diagnoses and treated for asthma. It occurs almost exclusively in women in their third, fourth, and fifth decades who have no identifiable cause of airway stenosis. Its cause remains unknown. 1 Patients are considered to have ILTS if they have an inflammatory cicatricial stenosis of the subglottis, upper trachea, or both and known causes are excluded. Known causes of subglottic stenosis include post-intubation injury; airway trauma, including external injury; inhalational burns and irradiation; specific and nonspecific
Study Objective: Though select inpatient-based performance measures exist for the care of patient... more Study Objective: Though select inpatient-based performance measures exist for the care of patients with nontraumatic intracranial hemorrhage (ICH), Emergency Departments (EDs) lack measurement instruments designed to support and improve care processes in the hyperacute phase. To address this, we propose a set of measures applying a syndromic (rather than diagnosis-based) approach informed by performance data from a national sample of community EDs participating in the Emergency Quality Network Stroke Initiative (E-QUAL). Methods: We convened a workgroup of experts in acute neurologic emergencies. The group considered the appropriate use case for each proposed measure (internal quality improvement [QI], benchmarking, or accountability) and examined data from E-QUAL-participating EDs to consider the validity and feasibility of proposed measures. The initially conceived set included 14 measure concepts of which 7 were selected for inclusion in the measure set after review of data and f...
Background Research suggests nonoccupational Post Exposure Prophylaxis (nPEP) is underprescribed ... more Background Research suggests nonoccupational Post Exposure Prophylaxis (nPEP) is underprescribed when indicated in the Emergency Department (ED). This study is an assessment of ED providers’ attitudes and practices regarding administration of HIV nPEP. Methods This was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED providers at work over a 4-month period from 5 hospital-based and 2 freestanding EDs with an annual census between 35,000 and 75,000 patients. The EDs are a combination of urban, suburban, and rural EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants. Results The majority of surveyed providers (133/149, 89.3%) believe it is their responsibility as an emergency provider to provide HIV nPEP in the emergency department (Figure 1). Although 91% (138/151) and 87% (132/151) of respondents are willing to prescribe nPEP to a patient in the ED for IV drug use and unprotected sex, respec...
ICU LOS was 23.0 days [IQR 12.8-37.0]. Five of the 18 (27.8%) died in hospital. The most frequent... more ICU LOS was 23.0 days [IQR 12.8-37.0]. Five of the 18 (27.8%) died in hospital. The most frequent pathogens were Staphylococcus aureus, Haemophilus influenza, oral flora, and Serratia marcescens. Conclusions: In this study, the incidence of VAP from patients intubated in the ED was low and not significantly different from patients intubated outside of the ED, suggesting that ED intubation may not present an increased risk for VAP. This study was limited by the small number of patients meeting the criteria for VAP. The few ED intubated patients who developed VAP had a high mortality. Further research is needed to assess the potential contribution of ED intubation on risk for VAP.
Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on p... more Fluid responsiveness is proposed as a physiology-based method to titrate fluid therapy based on preload dependence. The objectives of this study were to determine if a fluid responsiveness protocol would decrease progression of organ dysfunction, and a fluid responsiveness protocol would facilitate a more aggressive resuscitation. Methods: Prospective, 10-center, randomized interventional trial. Inclusion criteria: suspected sepsis and lactate 2.0 to 4.0 mmol/L. Exclusion criteria (abbreviated): systolic blood pressure more than 90 mmHg, and contraindication to aggressive fluid resuscitation. Intervention: fluid responsiveness protocol using Non-Invasive Cardiac Output Monitor (NICOM) to assess for fluid responsiveness (>10% increase in stroke volume in response to 5 mL/kg fluid bolus) with balance of a liter given in responsive patients. Control: standard clinical care. Outcomes: primary-change in Sepsis-related Organ Failure Assessment (SOFA) score at least 1 over 72 h; secondary-fluids administered. Trial was initially powered at 600 patients, but stopped early due to a change in sponsor's funding priorities. Results: Sixty-four patients were enrolled with 32 in the treatment arm. There were no significant differences between arms in age, comorbidities, baseline vital signs, or SOFA scores (P > 0.05 for all). Comparing treatment versus Standard of Care-there was no difference in proportion of increase in SOFA score of at least 1 point (30% vs. 33%) (note bene underpowered, P ¼ 1.0) or mean preprotocol fluids 1,050 mL (95% confidence interval [CI]: 786-1,314) vs. 1,031 mL (95% CI: 741-1,325) (P ¼ 0.93); however, treatment patients received more fluids during the protocol (2,633 mL [95% CI: 2,264-3,001] vs. 1,002 mL [95% CI: 707-1,298]) (P < 0.001). Conclusions: In this study of a ''preshock'' population, there was no change in progression of organ dysfunction with a fluid responsiveness protocol. A noninvasive fluid responsiveness protocol did facilitate delivery of an increased volume of fluid. Additional properly powered and enrolled outcomes studies are needed.
Journal of the American College of Emergency Physicians Open
Objectives: Most acute stroke research is conducted at academic and larger hospitals, which may d... more Objectives: Most acute stroke research is conducted at academic and larger hospitals, which may differ from many non-academic (ie, community) and smaller hospitals with respect to resources and consultant availability. We describe current emergency department (ED) and hospital-level stroke-related capabilities among a sample of community EDs participating in the Emergency Quality Network (E-QUAL) stroke collaborative. Methods: Among EQUAL participating EDs, we conducted a survey to collect data on ED and hospital stroke-related structural and process capabilities associated with quality of stroke care delivery and patient outcomes. EDs submitted data using a web-based submission portal. We present descriptive statistics of self-reported capabilities.
Journal of the American College of Emergency Physicians Open, 2021
Equity in the promotion of women and underrepresented minorities (URiM) is essential for the adva... more Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward‐thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM).
The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and f... more The Accreditation Council for Graduate Medical Education (ACGME), which regulates residency and fellowship training in the United States, recently revised the minimum standards for all training programs. These standards are codified and published as the Common Program Requirements. Recent specific revisions, particularly removing the requirement ensuring protected time for core faculty, are poised to have a substantial impact on emergency medicine training programs. A group of representatives and relevant stakeholders from national emergency medicine (EM) organizations was convened to assess the potential effects of these changes on core faculty and the training of emergency physicians. We reviewed the literature and results of surveys conducted by EM organizations to examine the role of core faculty protected time. Faculty nonclinical activities contribute greatly to the academic missions of EM training programs. Protected time and reduced clinical hours allow core faculty to engage in education and research, which are two of the three core pillars of academic EM. Loss of core faculty protected time is expected to have detrimental impacts on training programs and on EM generally. We provide consensus recommendations regarding EM core faculty clinical work hour limitations to maintain protected time for educational activities and scholarship and preserve the quality of academic EM. BACKGROUND T he Accreditation Council for Graduate Medical Education (ACGME) regulates residency and fellowship training in the United States by establishing minimum standards for accredited residency programs. The ACGME has developed, and periodically updates, the Common Program Requirements (CPRs) that apply to all ACGME accredited residencies. The CPRs
Journal of the American College of Radiology, 2019
Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients pres... more Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients presenting for treatment. Cervical spine injuries occur in 3% to 4% and thoracolumbar fractures in 4% to 7% of blunt trauma patients presenting to the emergency department. Clear, validated criteria exist for screening the cervical spine in blunt trauma. Screening criteria for cervical vascular injury and thoracolumbar spine injury have less validation and widespread acceptance compared with cervical spine screening. No validated criteria exist for screening of neurologic injuries in the setting of spine trauma. CT is preferred to radiographs for initial assessment of spine trauma. CT angiography and MR angiography are both acceptable in assessment for cervical vascular injury. MRI is preferred to CT myelography for assessing neurologic injury in the setting of spine trauma. MRI is usually appropriate when there is concern for ligament injury or in screening obtunded patients for cervical spine instability.
Procedure Appropriateness Category Relative Radiation Level Radiography chest Usually Appropriate... more Procedure Appropriateness Category Relative Radiation Level Radiography chest Usually Appropriate ☢ US chest May Be Appropriate O Radiography rib views Usually Not Appropriate ☢☢☢ MRI chest without and with IV contrast Usually Not Appropriate O MRI chest without IV contrast Usually Not Appropriate O Bone scan whole body Usually Not Appropriate ☢☢☢ CT chest with IV contrast Usually Not Appropriate ☢☢☢ CT chest without and with IV contrast Usually Not Appropriate ☢☢☢ CT chest without IV contrast Usually Not Appropriate ☢☢☢ FDG-PET/CT skull base to mid-thigh Usually Not Appropriate ☢☢☢☢ WBC scan chest Usually Not Appropriate ☢☢☢☢
A 22-year-old male with sickle-cell trait presented with a 1-week history of progressive pain and... more A 22-year-old male with sickle-cell trait presented with a 1-week history of progressive pain and swelling in his left posterior thigh. He denied any trauma, fever, travel outside of the United States, or intravenous drug usage. On examination, he was afebrile at 36.8 °C (98.3 °F) with stable vital signs. His examination was significant for exquisite tenderness, erythema, induration, and swelling of the posterior thigh (Fig. 1). A computed tomography scan of the extremity was obtained that showed a 5.5cm × 4.4 cm × 20-cm fluid collection within the biceps femoris muscle (Fig. 2). The patient underwent open drainage of the abscess and was placed on linezolid. Wound and blood cultures were consistent with community-associated meth-icillin-resistant Staphylococcus aureus (ca-MRSA). Pyomyositis is an acute bacterial infection of the muscles characterized by subacute abscess formation. While pyo-myositis is rare in temperate climates, the incidence has been increasing, with the majority ...
Burnout is a complex syndrome thought to result from long‐term exposure to career‐related stresso... more Burnout is a complex syndrome thought to result from long‐term exposure to career‐related stressors. Physicians are at higher risk for burnout than the general United States (US) working population, and emergency medicine has some of the highest burnout rates of any medical specialty. Burnout impacts physicians’ quality of life, but it can also increase medical errors and negatively affect patient safety. Several studies have reported lower burnout rates and higher job satisfaction in academic medicine as compared with private practice. However, researchers have only begun to explore the factors that underlie this protective effect. This paper aims to review existing literature to identify specific aspects of academic practice in emergency medicine that may be associated with lower physician burnout rates and greater career satisfaction. Broadly, it appears that spending time in the area of emergency medicine one finds most meaningful has been associated with reduced physician burno...
Aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer are parts of a spec... more Aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcer are parts of a spectrum of acute aortic syndromes that represent uncommon--but potentially deadly--diagnoses seen in the emergency department. The differential for acute aortic syndromes is large, as many conditions (including the much more common conditions of acute coronary syndromes and pulmonary embolism) present with many of the same chief complaints. This review looks at the features and classifications of acute aortic syndromes and presents evidence regarding the risk factors and chief complaints that can assist emergency clinicians in identifying the patients who require further investigation. Although no set of clinical factors has been shown to rule out aortic dissection, elements of a complete history and physical examination are critical in identifying patients who may be at risk for these diseases. In addition, the advantages and disadvantages of the various available advanced imaging strategi...
Journal of the American College of Emergency Physicians Open
A 48-year-old male presents with low back pain after falling off a ladder. He states he was climb... more A 48-year-old male presents with low back pain after falling off a ladder. He states he was climbing up a ladder when he slipped and fell on
Background: Left ventricular assist devices (LVADs) are used to treat patients with end-stage hea... more Background: Left ventricular assist devices (LVADs) are used to treat patients with end-stage heart failure, either as a bridge to heart transplantation or as destination therapy for patients not suitable for heart transplant. The number of patients with LVADs and the number of medical centers in the United States involved in implantation of these devices is increasing. Although the HeartWare Ventricular Assist Device (Medtronic) is currently the most common implant, based on previous popularity, there are still more HeartMate IIs (HMIIs) (Abbott Laboratories) currently in use. Given the high likelihood that a patient with an LVAD will seek ED care at some point, emergency physicians must be able to identify and manage the complications associated with these devices. The purpose of this study was to identify the type, frequency, and disposition of patients with an HMII LVAD who presented to an urban tertiary care referral center ED. Methods: This was a retrospective study of patients with an HMII LVAD who presented to an urban ED between April 1, 2009 and September 9, 2012. All patients with an HMII LVAD who presented to the ED were included in the study, and there were no exclusion criteria. Electronic medical records were reviewed by study investigators to identify all ED visits by HMII LVAD patients during the study period to identify the reason for presentation, the frequency of ED visits, and final patient disposition. Results: A total of 98 patients in the catchment area had an HMII LVAD implanted during the study period. Sixty-seven (68%) of these presented to the ED, for a total of 248 ED visits. The average number of ED visits per patient was 3.7. The most common reasons for presentation included bleeding (14.9%); volume overload (14.9%), weakness/lightheadedness/dizziness/syncope (9.6%), device malfunction (8.1%), and infection (2.8%). Approximately 56% of the ED visits were directly LVAD-related. Fifty-seven percent of the patients required admission to the hospital. Conclusions: Approximately two-thirds of patients with an HMII LVAD presented to the ED, many of whom presented multiple times. The most common complications observed were bleeding and volume overload. Fifty-seven percent of these patients required hospitalization.
Policy statements and clinical policies are the official policies of the American College of Emer... more Policy statements and clinical policies are the official policies of the American College of Emergency Physicians and, as such, are not subject to the same peer review process as articles appearing in the journal. Policy statements and clinical policies of ACEP do not necessarily reflect the policies and beliefs of Annals of Emergency Medicine and its editors.
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Papers by Bruce M Lo