Emergency Medicine

Background: Workers in blue-collar and service occupations smoke at higher rates than workers in white-collar and professional occupations. Occupational stress may explain some of the occupational class differences in smoking and quitting behavior. The purpose of this study is to investigate the contribution of occupational factors to smoking behavior over a ten year period among a multiethnic cohort of urban transit operators, while accounting for demographic factors and alcohol. Methods: The sample consists of 654 San Francisco Municipal Railway (MUNI) transit operators who participated in two occupational health studies and biennial medical examinations during 1983-85 and 1993-95. Workers who had initiated, increased, or maintained their smoking over the ten year period were compared to workers who remained non-smokers. Occupational factors included self-rated frequency of job problems (e.g., difficulties with equipment, passengers, traffic), job burnout (i.e., the emotional exhaustion subscale of the Maslach Burnout Inventory), time needed to unwind after work, and years employed as a transit operator. A series of logistic regression models were developed to estimate the contribution of occupational factors to smoking behavior over time. Results: Approximately 35% of the workers increased, initiated, or maintained their smoking over the ten-year period. Frequency of job problems was significantly associated with likelihood of smoking increase, initiation, or maintenance (OR = 1.30; 95% CI 1.09, 1.55). Black operators were significantly more likely to have smoked over the ten-year period compared to operators in other racial/ethnic groups. Conclusion: Understanding the role of work-related stress vis-à-vis smoking behavior is of critical importance for crafting workplace smoking prevention and cessation interventions that are applicable to blue-collar work settings, and for developing policies that mitigate occupational stress. Background Smoking is the leading cause of preventable death in the U.S. [1]. Although rates of cigarette smoking have declined over the past decades, the rates of decline have varied by gender, ethnicity, and occupational status [2], resulting in significant tobacco-related health disparities

Assessment of volume status in critically ill patients poses a challenge to clinicians. Measuring changes in the inferior vena cava (IVC) diameter using ultrasound is becoming a standard tool to assess volume status. Ultrasound requires physicians with significant training and specialized expensive equipment. It would be of significant value to be able to obtain this measurement continuously without physician presence. We hypothesize that dynamic changes in limb's bio-impedance in response to respiration could be used to predict changes in IVC. Forty-six subjects were tested a hemodialy-sis session. Impedance was measured via electrodes placed on the arm. Simultaneously, the IVC diameter was assessed by ultrasound. Subjects were asked to breathe spontaneously and perform respiratory maneuvers using a respiratory training device. Impedance (dz) was determined and compared with change in IVC diameter (dIVC; r = 0.76, p < 0.0001). There was significant relationship between dz and dIVC (p < 0.0001). Receiver-operator curves for dz at thresholds of dIVC (20% to70%) demonstrated high predictive power with areas under the curves (0.87–0.99, p < 0.0001). This evaluation suggests that real-time dynamic changes in limb impedance are capable of tracking a wide range of dynamic dIVC. This technique might be a suitable surrogate for monitoring real-time changes in dIVC to assess intravascular volume status. Monitoring and assessment of a patient's volume status and fluid responsiveness is an integral part of the management plan of critically ill patients as well as others for whom volume management has significant outcome implications. Rapid and accurate volume determinations are important for preventing under or over resuscitation of critically ill and injured patients that can result in higher rates of secondary injury and mortality. These same considerations also extend to patients with chronic conditions such as heart failure and chronic kidney disease. 1–6 Development of noninvasive and easy to use tools to make these assessments would be a welcome addition to the management of these patients. The dynamic relationship between venous return, the function of the right ventricle, and its interaction with lung mechanics are key determinants of estimating intravascular volume status and more importantly, the patient's functional response to addition or removal of volume. 7,8 The use of real-time ultrasound to view the collapse or distention of the inferior vena cava (IVC) during respiration is a useful tool to estimate volume responsiveness and guide intravenous fluid management. 9–18 Inferior vena cava ultrasound requires physicians with significant training and specialized expensive equipment. Inferior vena cava measurements are difficult to obtain in obese patients and patients with significant amounts of bowel gas. Inferior vena cava measurements require a physician to be present at the bedside for each measurement making frequent measures to follow treatment logistically challenging. It would be of significant value to be able to obtain this measurement on a continuous basis without physician presence for each measurement. Bioimpedance—a measure of a tis-sue's resistance to an induced current or voltage 19,20 —has been used to monitor fluid status, nutritional status, and lung water. When applied to either the whole body or a portion thereof, bioimpedance becomes the cumulative effect of the individual impedances of components under examination. These components in the body consist of muscle tissue, fat, intracellular and extracellular fluid, and blood. Blood, as a good conductor of electricity, has a distinct effect on limb impedance as the respiratory cycles significantly shift blood volume in the limb. That is, the impedance of a limb increases with decreased blood volume in the limb—as occurs during spontaneous inspiration as blood return is increased to the thorax through the mechanism of enhanced intrathoracic negative pressure— and decreases with increased blood volume in the limb—as is the case during spontaneous expiration. These effects are exaggerated with respiratory maneuvers like deep inspiration. Furthermore, because venous compliance is up to 30 times greater than its arterial counterpart, 21,22 volume change occurring within a limb during respiration will largely be a function of venous blood return. Aim We tested a new noninvasive technique to assess volume status. Our approach was to utilize single-frequency

OBJECTIVES: To develop and characterize an automated syndromic surveillance mechanism for early identification of older emergency department (ED) patients with possible life-threatening infection.DESIGN: Prospective, consecutive-enrollment, single-site observational study.SETTING: A large university medical center with an annual ED census of 75,273.PARTICIPANTS: Patients aged 70 and older admitted to the ED and having two or more systemic inflammatory response syndrome (SIRS) criteria during their ED stay.MEASUREMENTS: A search algorithm was developed to screen the census of the ED through its clinical information system. A study coordinator confirmed all patients electronically identified as having a probable infectious explanation for their visit.RESULTS: Infection accounted for 28% of ED and 34% of final hospital diagnoses. Identification using the software tool alone carried a 1.63 relative risk of infection (95% confidence interval CI=1.09–2.44) compared with other ED patients sufficiently ill to require admission. Follow-up confirmation by a study coordinator increased the risk to 3.06 (95% CI=2.11–4.44). The sensitivity of the strategy overall was modest (14%), but patients identified were likely to have an infectious diagnosis (specificity=98%). The most common SIRS criterion triggering the electronic notification was the combination of tachycardia and tachypnea.CONCLUSION: A simple clinical informatics algorithm can detect infection in elderly patients in real time with high specificity. The utility of this tool for research and clinical care may be substantial.

Objectives:  The objectives were to determine the frequency of administration of potentially inappropriate medications (PIMs) to older emergency department (ED) patients and to examine recent trends in the rates of PIM usage.Methods:  The data examined during the study were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS). This study utilized the nationally representative ED data from 2000–2006 NHAMCS surveys. Our sample included older adults (age 65 years and greater) who were treated in the ED and discharged home. Estimated frequencies of PIM-associated ED visits were calculated. A multivariable logistic regression model was created to assess demographic, clinical, and hospital factors associated with PIM administration and to assess temporal trends.Results:  Approximately 19.5 million patients, or 16.8% (95% confidence interval [CI] = 16.1% to 17.4%) of eligible ED visits, were associated with one or more PIMs. The five most common PIMs were promethazine, ketorolac, propoxyphene, meperidine, and diphenhydramine. The total number of medications prescribed or administered during the ED visit was most strongly associated with PIM use. Other covariates associated with PIM use included rural location outside of the Northeast, being seen by a staff physician only (and not by a resident or intern), presenting with an injury, and the combination of female sex and age 65–74 years. There was a small but significant decrease in the proportion of visits associated with a PIM over the study period.Conclusions:  Potentially inappropriate medication administration in the ED remains common. Given rising concerns about preventable complications of medical care, this area may be of high priority for intervention. Substantial regional and hospital type (teaching versus nonteaching) variability appears to exist.ACADEMIC EMERGENCY MEDICINE 2010; 17:231–237 © 2010 by the Society for Academic Emergency Medicine

Introduction: We investigated the degree of functional decline and loss of independence among older adults presenting to the emergency department (ED) with serious infection and to estimate 90-day case fatality. Methods: Consecutive patients 70 years or older (n = 50) presenting to the ED with potentially serious infection were identified using an automated case-identification algorithm. Fifty age-and sex-matched controls were recruited from a registry of community volunteers. Functional and residential statuses were ascertained at hospital admission, discharge, and 90 days. Details regarding patients' comorbidities, acute illness, and diagnostic evaluation were collected along with 90-day survival. Results: Older adults with suspected sepsis had substantial 90-day mortality (32.0%). Baseline functional impairment was more severe among cases than among control subjects, although activities of daily living and instrumental activities of daily living deficits did not predict outcome. Hospital admission was also not uniformly associated with deterioration in either activities of daily living or instrumental activities of daily living performance. Patients admitted from home were at no greater risk of functional decline than were those admitted from care facilities. No enrolled case enjoyed an increase in residential independence after discharge; of the 28 who were independent upon admission, 19 survived to 90 days, and 8 of the 19 required visiting assistance or were in a care facility. Conclusions: Older adults presenting to the ED with potentially serious infection have significant 90-day mortality. Although functional status does not consistently deteriorate in survivors, there seems to be considerable risk in the short-term for loss of residential independence.

Background:  The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes.Objectives:  The objective was to develop a consensus document, “Geriatric Competencies for Emergency Medicine Residents,” by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training.Methods:  This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project.Results:  In Phase I, participants (n = 363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n = 24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions.Conclusions:  The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population.ACADEMIC EMERGENCY MEDICINE 2010; 17:316–324 © 2010 by the Society for Academic Emergency Medicine

The Society for Emergency Medicine (SAEM) Geriatrics Task Force has created an instructional tool to address the complaint of abdominal pain in older adults presenting to the emergency department (ED). This is the first module in a comprehensive, web-based geriatric emergency medicine curriculum that will address common syndromes in older adults presenting to the ED. There is no formal, residency-based curriculum in geriatric emergency medicine and there is a paucity of geriatric Continuing Medical Education (CME) opportunities for practicing emergency physicians. The amount, quality, and convenience of geriatrics training available to emergency physicians is insufficient. This educational gap is particularly concerning given the ever-growing volume of older adult emergency patients. The Task Force chose to focus first on geriatric abdominal pain because a survey of emergency physicians in the mid 1990s found that it is one of the most difficult complaints to evaluate and manage. The module comprises of six clinical cases with a pre- and post-test. Together, these cases encompass the broad differential diagnosis for geriatric abdominal pain and the core medical knowledge pertaining to the subject. The modules will expose the learner, through either content or modeling, to the six Accreditation Council for Graduate Medical Education (ACGME) core competencies and to the Principles of Geriatric Emergency Medicine including rapid evaluation of functional status, communication skills, and consideration of the effect of polypharmacy and co-morbidity on the presenting complaint. This module will be available to residency programs as an “asynchronous educational session” via the Council of Emergency Medicine Residency Directors (CORD) website as well as to practicing emergency physicians via the SAEM and American College of Emergency Physicians (ACEP) websites.

Objectives: With the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System, emergency medicine (EM) residency programs will be required to report residents' progress through the EM milestones. The milestones include five progressively advancing skill levels, with Level 1 defining the skill set of a medical school graduate and Level 5, that of an attending physician. The ACGME stresses that multiple forms of assessment should be used to ensure capture of the multifaceted competencies. The objective of this study was to determine the feasibility and results of programmatic assessment of Level 1 milestones using multisource assessments for incoming EM interns in July. Methods: The study population was interns starting in 2012 and 2013. Interns' Level 1 milestone assessment was done with four distinct methods: 1) the postgraduate orientation assessment (POA) by the Graduate Medical Education Office for all incoming interns (this multistation examination covers nine of the EM milestones and includes standardized patient cases, task completion, and computer-based stations); 2) direct observation of patient encounters by core faculty using a milestones-based clinical skills competency checklist; 3) the global monthly assessment at the end of the intern orientation month that was updated to reflect the EM milestones; and 4) faculty assessment during procedural labs. These occurred during the July orientation month that included the POA, clinical shifts, didactic sessions, and procedure labs.

Background: The Multiple Mini-Interview (MMI) uses short, structured contacts, and is known to predict medical school success better than traditional interviews and application materials. Its utility in Emergency Medicine residency selection is untested. Objectives: We investigate whether it provides additional information regarding future first-year resident performance that can be useful in resident selection. Methods: From three Emergency Medicine residency programs, 71 interns in their first month completed an MMI developed to focus on desirable resident characteristics. Application data were reviewed. First-year resident performance assessments covering the American Council for Graduate Medical Education (ACGME) core competencies, along with professionalism and performance concerns, were obtained. Multiple logistic regressions were employed and MMI correlations were compared with program rank lists and typical selection factors. Results: An individual's score on the MMI correlated with overall performance (p < 0.05) in single logistic regression. MMI correlated with ACGME individual competencies patient care and procedural skills at a less robust level (p < 0.1), but not with any other outcomes. Rank list position correlated with the diagnostic skill competency (p < 0.05), but no others. Traditional selection factors correlated with overall performance, disciplinary action, patient care, medical knowledge, and diagnostic skills (p < 0.05). MMI was not correlated significantly with the outcomes when included in multiple ordinal logistic regression with other selection factors. Conclusions: MMI scores correlate with overall performance, but are not statistically significant when other traditional selection factors were considered. The MMI process seems potentially superior to program rank list at correlating with first-year performance. The MMI may provide additional benefit when examined using a larger and more diverse sample.

We report an asplenic patient who was infected with Babesia divergens-like/MO-1. The clinical course was complicated by multiorgan failure that required intubation and dialysis. The patient recovered after an exchange transfusion and antimicrobial drug therapy. Physicians should be alert for additional cases, particularly in asplenic persons.

Background Due to the COVID-19 pandemic, clinical rotations at the University of Michigan Medical School (UMMS) were suspended on March 17, 2020, per the Association of American Medical Colleges’ recommendations. No alternative curriculum existed to fill the educational void for clinical students. The traditional approach to curriculum development was not feasible during the pandemic as faculty were redeployed to clinical care, and the immediate need for continued learning necessitated a new model. Approach One student developed an outline for an online course on pandemics based on peer-to-peer conversations regarding learners’ interests and needs, and she proposed that students author the content given the immediate need for a curriculum. Fifteen student volunteers developed content to fill knowledge gaps, and expert faculty reviewers confirmed that the student authors had successfully curated a comprehensive curriculum. Evaluation The crowdsourced student content coalesced into a ...

Background and objective Although hospitalization is required for only a minority of those infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the high rates of morbidity and mortality among these patients have led researchers to focus on the predictors of admission and adverse outcomes in the inpatient population. However, there is scarce data on the clinical trajectory of individuals symptomatic enough to present for emergency care, but not sick enough to be admitted. In light of this, we aimed to examine the symptomatology, emergency department (ED) revisits, and hospitalization of coronavirus disease 2019 (COVID-19) outpatients after discharge from the ED. Methods Adult patients with COVID-19 infection were prospectively enrolled after discharge from the ED between May and December 2020. Patients were followed up longitudinally for 14 days via phone interviews designed to provide support and information and to track symptomatology, ED revisits, and hospitalization. Results A volunteer, medical student-run program enrolled 199 COVID-19 patients discharged from the ED during the first nine months of the pandemic. Of the 176 patients (88.4%) who completed the 14-day protocol, 29 (16.5%) had a second ED visit and 17 (9.6%) were admitted, 16 (9%) for worsening COVID-19 symptoms. Age, male sex, comorbid illnesses, and self-reported dyspnea, diarrhea, chills, and fever were associated with hospital admission for patients with a subsequent ED visit. For those who did not require admission, symptoms generally improved following ED discharge. Age >65 years and a history of cardiovascular disease (CVD) were associated with a longer duration of cough, but generally, patient characteristics and comorbidities did not significantly affect the overall number or duration of symptoms. Conclusions Nearly one in five patients discharged from the ED with COVID-19 infection had a second ED evaluation during a 14-day follow-up period, despite regular phone interactions aimed at providing support and information. More than half of them required admission for worsening COVID-19 symptoms. Established risk factors for severe disease and self-reported persistence of certain symptoms were associated with hospital admission, while those who did not require hospitalization had a steady improvement in symptoms over the 14-day period.

Conclusion The rising national rate of TBI-related deaths due to falls highlights an emerging priority area for prevention. Targeted interventions to reduce incidence of this health event, especially among older adults and those living in non-metropolitan counties is needed.