Handheld bedside ultrasound in the diagnosis of myocarditis

Myocarditis is a disease process that every emergency physician fears missing.Its severity can be mild to life-threatening,and many cases are likely undetected because they are subclinical with nonspecifi c signs.[1]Subtle cardiac signs may be overshadowed by systemic symptoms of the underlying infectious process.Fever,myalgias,lethargy,symptoms commonly associated with viral syndrome,can mask the life-threatening myocarditis that may be present.In fact,in the United States Myocarditis Treatment Trial,almost 90%of patients reported symptoms consistent with a viral prodrome.[2]Ammirati et al[3]reported that 27%of patients with myocarditis had either reduced left ventricular ejection fraction,ventricular arrhythmias,or low cardiac output.Here,we present a case report,in which handheld point-of-care ultrasound was utilized at the bedside to aid in the critical diagnosis of myocarditis.With the additional information provided through this imaging modality,this patient was able to be transferred to the appropriate tertiary care facility in an expeditious manner and receive possible defi nitive treatment.

Can emergency physicians perform extended compression ultrasound for the diagnosis of lower extremity deep vein thrombosis?

BACKGROUND:Current point-of-care ultrasound protocols in the evaluation of lower extremity deep vein thrombosis (DVT) can miss isolated femoral vein clots.Extended compression ultrasound (ECUS) includes evaluation of the femoral vein from the femoral vein/deep femoral vein bifurcation to the adductor canal.Our objective is to determine if emergency physicians (EPs) can learn ECUS for lower extremity DVT evaluation after a focused training session.METHODS:Prospective study at an urban academic center.Participants with varied ultrasound experience received instruction in ECUS prior to evaluation.Two live models with varied levels of difficult sonographic anatomy were intentionally chosen for the evaluation.Each participant scanned both models.Pre-and post-study surveys were completed.RESULTS:A total of 96 ultrasound examinations were performed by 48 participants (11 attendings and 37 residents).Participants' assessment scores averaged 95.8% (95% CI 93.3%-98.3%) on the easier anatomy live model and averaged 92.3% (95% CI 88.4%-96.2%) on the difficult anatomy model.There were no statistically significant differences between attendings and residents.On the model with easier anatomy,all but 1 participant identified and compressed the proximal femoral vein successfully,and all participants identified and compressed the mid and distal femoral vein.With the difficult anatomy,97.9% (95% CI93.8%-102%) identified and compressed the proximal femoral vein,whereas 93.8% (95% CI 86.9%-100.6%) identified and compressed the mid femoral vein,and 91.7% (95% CI83.9%-99.5%) identified and compressed the distal femoral vein.CONCLUSION:EPs at our institution were able to perform ECUS with good reproducibility after a focused training session.

The Training and Performance of Emergency Physicians as Anesthetists for International Medical Surgical Response Teams: The Emergency Physician’s General Anesthesia Syllabus (EP GAS)

Background: The availability of an anesthesiologist is often a limiting factor in the number of operations that can be performed by International Medical Surgical Response Teams (IMSuRT). Because emergency physicians (EPs) possess skills in airway control, management of moderate and deep sedation, and ventilator management, we propose that with proper training in general anesthesia, EPs can serve as anesthetists for IMSuRT with anesthesiologist supervision. Methods: During a 10-week period, a board-certified EP administered general anesthesia to 60 patients prior to a surgical medical mission trip. The breakdown of surgical cases was: 11 orthopedic, 2 genitourinary, 20 ear, nose, and throat, 8 obstetrics and gynecological, 13 general surgery, and 6 vascular. A simplified protocol for induction, maintenance, and emergence was adhered to for all cases. Results: Fourteen orthopedic cases using general anesthesia were performed in a one-week period in Haiti. These cases involved open reduction and internal fixation (ORIF), hemiarthoplasty, hardware removal, tendon transfer and external fixation of fractured bone. Conclusion: We demonstrate the feasibility of a model curriculum to train EPs in the basics of anesthesia. The EP can safely and effectively deliver general anesthesia for major cases on surgical medical mission trips under the auspices of an anesthesiologist in an austere environment.

Mobile technology:Usage and perspective of patients and caregivers presenting to a tertiary care emergency department

BACKGROUND:Developments in information technology(IT)have driven a push in healthcare innovation in the emergency department(ED).Many of these applications rely on mobile technology(MT)such as smartphones but not everyone is comfortable with MT usage.Our study aims to characterize the technology usage behavior of users in the ED so as to guide the implementation of IT interventions in the ED.METHODS:A cross-sectional survey was conducted in the emergency department of a tertiary hospital.Patients and their caregivers aged 21 and above were recruited.The survey collected demographic information,technology usage patterns,and participant reported comfort level in the usage of MT.We performed descriptive statistics and multivariate logistic regression to identify factors differentially associated with comfort in usage of MT.RESULTS:A total of 498 participants were recruited,and 299(60%)were patients.English was the most commonly written and read language(66.9%)and 64.2%reported a comfort level of 3/5 or more in using MT.Factors that were associated with being comfortable in using MT include having a tertiary education,being able to read and write English,as well as being a frequent user of IT.Caregivers were more likely to display these characteristics.CONCLUSION:A large proportion of ED patients are not comfortable in the usage of MT.Factors that predicted comfort level in the usage of MT were common amongst caregivers.Future interventions should take this into consideration in the design of MT interventions.

Conversion disorder in a neurological emergency department:Restrospective series

Objective: To observe the conversion disorder in a neurological emergency department. Methods: It is common that the initial approach to this patients include the use of various diagnostic exams. In this series we reviewed 94 patients that arrived a neurological emergency room in a 3 year period. Results: 72 patients were females (76%), and the initial presumptive diagnosis were: neurovascular syndrome in 36 patients (38.3%), convulsive disorder in 20 patients (21.28%), and conversive disorder in 8 patients (8.51%). 82 patients had motor symptoms and 61 sensitive symptoms. 88 patients (93%) required neuroimaging studies, 77 (81%) patients underwent through basic biochemical panels. Other tests performed were:electroencephalogram in 12 patients (12.77%), electromyography in 11 patients (11.7%), lumbar punction in 8 patients (8.04%) and regarding the medical consult in the care of these patients 11 were evaluated by 1 specialists, 35 (37.2%) by 2 different specialties, 42 (44.63%) patients required evaluation by 3, and 6 patients (6.38%) required evaluation by 4 different specialties. Conclusions: Based on this data, we conclude that conversion disorders require a lot of resources in the emergency room and that the similarities with neurological diseases demands a complete workup including expensive diagnostic tools. However, this patients can be discharged safely without requiring hospitalization.

The Aging Waistline: Impact of the Geriatric Obesity Epidemic on an Urban Emergency Department: Original Communication

Purpose: Reviews adult emergency department (ED) visits for patients age 65 and older during one calendar year;determine the prevalence of weight classifications;identifies trends between BMI and discharge/admitting diagnoses, vital signs, and severity index.Methods: The electronic medical records system and data from the ED billing service was reviewed for an urban academic institution with an annual volume of 125,000 for patients age > 65. Using a random number table, a retrospective cohort of 328 elderly patients was selected for review, representing a convenience sample of 2.6% of elderly ED visits. Body Mass Index (BMI) was calculated, using the Center for Disease Control (CDC) formula with underweight (- 24.9), overweight (25 - 29.9), and obese (≥30). Results: The majority of the cohort in this study was African-American and Hispanic (60% and 27% respectively), and there were a higher percentage of females than males (60% and 40% respectively). Approximately 29% of the patients were classified as normal weight, 35% classified as overweight, and 36% as obese. The older the patient, the more likely that patient belonged to a lower weight classification (p 0.01). Those presenting with neurological, pulmonary or gastrointestinal complaints were more likely to be of a higher weight classification (p 0.05). Patients who were hypertensive on arrival to the ED were more likely to be in a higher weight classification (p 0.01). Conclusion: Those patients with a higher weight classification had a strong correlation with selected abnormal vital signs and disease presentations. EDs are important sources of care for the elderly. EDs can serve as a previously untapped resource for screening and early referral exercise programs aimed at improving physical function/ functional status and quality of life in the elderly patient population.

A case of phenibut withdrawal and treatment with baclofen

Phenibut(β-phenyl-γ-aminobutyric acid)is a psychoactive gamma-aminobutyric acid(GABA)analog marketed online as a nutritional and nootropic(cognition enhancing)supplement.Phenibut consumption poses a high risk of potential abuse.Withdrawal from phenibut mimics benzodiazepine and alcohol withdrawal and can be dangerous.A number of approaches have been described for phenibut withdrawal,including protocols that include baclofen,but for inpatient and outpatient use.Here we describe a 30-year-old male who presented to an emergency department(ED)with insomnia,anxiety and palpitations after he stopped taking phenibut.

Prehospital system delay in patients with ST-segment elevation myocardial infarction in Singapore

BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction(STEMI)improves outcomes. System delay is that between first medical contact and reperfusion therapy,comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore.METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services(EMS),ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique.RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5minutes(interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes(IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes(IQR=1.30, 22.13); between arrival-at- and departurefrom-patient-location was 13.12 minutes(IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes(IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulancedispatch and arrival-at-patient-location was shorter(5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter(10.78 vs.14.37 minutes, P<0.01).CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.

Venous thromboembolism in a healthy young man:An unintended consequence of coronavirus disease 2019 pandemic lockdown

Dear editor,The coronavirus disease 2019(COVID-19)pandemic has enveloped the globe with ferocious pace,prompting lockdowns of countries and continents.Consequently,up to one-third of the world’s population is living in some forms of coronavirus mass quarantine,which brings new and unprecedented challenges to healthcare systems worldwide.One of these is the potentially deleterious effects of physical inactivity due to enacted restrictions.

A cadaveric model for transesophageal echocardiography transducer placement training: A pilot study

BACKGROUND: Transesophageal echocardiography(TEE) is used in the emergency department to guide resuscitation during cardiac arrest. Insertion of a TEE transducer requires manual skill and experience, yet in some residency programs cardiac arrest is uncommon, so some physicians may lack the means to acquire the manual skills to perform TEE in clinical practice. For other infrequently performed procedural skills, simulation models are used. However, there is currently no model that adequately simulates TEE transducer insertion. The aim of this study is to evaluate the feasibility and efficacy of using a cadaveric model to teach TEE transducer placement among novice users.METHODS: A convenience sample of emergency medicine residents was enrolled during a procedure education session using cadavers as tissue models. A pre-session assessment was used to determine prior knowledge and confidence regarding TEE manipulation. Participants subsequently attended a didactic and hands-on education session on TEE placement. All participants practised placing the TEE transducer until they were able to pass a standardized assessment of technical skill(SATS). After the educational session, participants completed a post-session assessment. RESULTS: Twenty-five residents participated in the training session. Mean assessment of knowledge improved from 6.2/10 to 8.7/10(95% confidence interval [CI] of knowledge difference 1.6–3.2, P<0.001) and confidence improved from 1.6/5 to 3.1/5(95% CI of confidence difference 1.1–2.0, P<0.001). There was no relationship between training level and the delta in knowledge or confidence.CONCLUSIONS: In this pilot study, the use of a cadaveric model to teach TEE transducer placement methods among novice users is feasible and improves both TEE manipulation knowledge and confidence levels.

Advocacy inquiry and circular questioning to maintain psychological safety in training,feedback,and conversations with residents

Training of emergency physicians through an emergency medicine residency program takes 5 years,that is,3 years in junior residency and 2 years in senior residency.Throughout this period,residents will be exposed to a variety of educational methodologies and meet a spectrum of faculty,supervisors,and teachers,who will have different personalities,styles,and approaches to teaching and nurturing them.It is important to ensure the maintenance of psychological safety for these residents throughout their training journey and into the future years of practice s an emergency physician.Communications,interactions(which involve questioning),and presentations will be an important part of this training program.This article looks at two modes of questioning:advocacy inquiry and circular questioning,which can be applied as appropriate.These two methods are examples in which faculty may consider adopting in their many interactions,follow-up,feedback,tutorials,facilitation,partnerships,and counseling sessions with residents.These two techniques offer options to maintain psychological safety,which can facilitate learners sharing and opening up.It can be included in the faculty’s armamentarium of questioning techniques and applied where applicable.