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1.  A Review of Lawsuits Related to Point-of-Care Emergency Ultrasound Applications 
Introduction
New medical technology brings the potential of lawsuits related to the usage of that new technology. In recent years the use of point-of-care (POC) ultrasound has increased rapidly in the emergency department (ED). POC ultrasound creates potential legal risk to an emergency physician (EP) either using or not using this tool. The aim of this study was to quantify and characterize reported decisions in lawsuits related to EPs performing POC ultrasound.
Methods
We conducted a retrospective review of all United States reported state and federal cases in the Westlaw database. We assessed the full text of reported cases between January 2008 and December 2012. EPs with emergency ultrasound fellowship training reviewed the full text of each case. Cases were included if an EP was named, the patient encounter was in the emergency department, the interpretation or failure to perform an ultrasound was a central issue and the application was within the American College of Emergency Physician (ACEP) ultrasound core applications. In order to assess deferred risk, cases that involved ultrasound examinations that could have been performed by an EP but were deferred to radiology were included.
Results
We identified five cases. All reported decisions alleged a failure to perform an ultrasound study or a failure to perform it in a timely manner. All studies were within the scope of emergency medicine and were ACEP emergency ultrasound core applications. A majority of cases (n=4) resulted in a patient death. There were no reported cases of failure to interpret or misdiagnoses.
Conclusion
In a five-year period from January 2008 through December 2012, five malpractice cases involving EPs and ultrasound examinations that are ACEP core emergency ultrasound applications were documented in the Westlaw database. All cases were related to failure to perform an ultrasound study or failure to perform a study in a timely manner and none involved failure to interpret or misdiagnosis when using of POC ultrasound.
doi:10.5811/westjem.2014.11.23592
PMCID: PMC4307691
2.  Evaluation of Healthcare Use Trends of High-Risk Female Intimate Partner Violence Victims 
Introduction
Practitioners need more information about intimate partner violence (IPV) victims’ healthcare use trends. We used a novel data-linkage method and complaint categorization allowing us to evaluate IPV victims healthcare use trends compared to the date of their victimization.
Methods
This was a retrospective case series using data-linking techniques cross-referencing databases of Medicaid-eligible women between the ages of 16 and 55 years, an IPV Case Database for 2007 and the Florida State Agency for Healthcare Administration, which tracks hospital inpatient, ambulatory and emergency department (ED) use within the State of Florida. We analyzed resulting healthcare visits 1.5 years before and 1.5 years after the women’s reported IPV offense. Using all available claims data a ‘complaint category’ representing categories of presenting chief complaints was assigned to each healthcare visit. Analysis included descriptive statistics, correlation coefficients between time of offense and visits, and a logistic regression analysis.
Results
The 695 victims were linked with 4,344 healthcare visits in the four-year study period. The victims were young (46% in the 16–25 age group and 79% were younger than 35). Healthcare visits were in the ED (83%) rather than other healthcare sites. In the ED, IPV victims mostly had complaint categories of obstetrics and gynaecology-related visits (28.7%), infection-related visits (18.9%), and trauma-related visits (16.3%). ED use escalated approaching the victim’s date of offense (r=0.59, p<0.0001) compared to use of non-ED sites of healthcare use (r=0.07, p=0.5817). ED use deescalated significantly after date of reported offense for ED visits (r=0.50, p<0.0001) versus non-ED use (r=0.00, p=0.9958). The victims’ age group more likely to use the ED than any other age group was the 36–45 age group (OR 4.67, CI [3.26–6.68]).
Conclusion
IPV victims use the ED increasingly approaching their date of offense. Presenting complaints were varied and did not reveal unique identifiers of IPV victims. This novel method of database matching between claims data and government records has been shown to be a valid way to evaluate healthcare utilization of at-risk populations.
doi:10.5811/westjem.2014.12.22866
PMCID: PMC4307692
3.  Anticoagulation Drug Therapy: A Review 
Historically, most patients who required parenteral anticoagulation received heparin, whereas those patients requiring oral anticoagulation received warfarin. Due to the narrow therapeutic index and need for frequent laboratory monitoring associated with warfarin, there has been a desire to develop newer, more effective anticoagulants. Consequently, in recent years many novel anticoagulants have been developed.
The emergency physician may institute anticoagulation therapy in the short term (e.g. heparin) for a patient being admitted, or may start a novel anticoagulation for a patient being discharged. Similarly, a patient on a novel anticoagulant may present to the emergency department due to a hemorrhagic complication. Consequently, the emergency physician should be familiar with the newer and older anticoagulants. This review emphasizes the indication, mechanism of action, adverse effects, and potential reversal strategies for various anticoagulants that the emergency physician will likely encounter.
doi:10.5811/westjem.2014.12.22933
PMCID: PMC4307693
4.  Low-Cost Alternative External Rotation Shoulder Brace and Review of Treatment in Acute Shoulder Dislocations 
Traumatic dislocations of the shoulder commonly present to emergency departments (EDs). Immediate closed reduction of both anterior and posterior glenohumeral dislocations is recommended and is frequently performed in the ED. Recurrence of dislocation is common, as anteroinferior labral tears (Bankart lesions) are present in many anterior shoulder dislocations.14,15,18,23 Immobilization of the shoulder following closed reduction is therefore recommended; previous studies support the use of immobilization with the shoulder in a position of external rotation, for both anterior and posterior shoulder dislocations.7–11,19 In this study, we present a technique for assembling a low-cost external rotation shoulder brace using materials found in most hospitals: cotton roll, stockinette, and shoulder immobilizers. This brace is particularly suited for the uninsured patient, who lacks the financial resources to pay for a pre-fabricated brace out of pocket. We also performed a cost analysis for our low-cost external rotation shoulder brace, and a cost comparison with pre-fabricated brand name braces. At our institution, the total materials cost for our brace was $19.15. The cost of a pre-fabricated shoulder brace at our institution is $150 with markup, which is reimbursed on average at $50.40 according to our hospital billing data. The low-cost external rotation shoulder brace is therefore a more affordable option for the uninsured patient presenting with acute shoulder dislocation.
doi:10.5811/westjem.2014.12.23068
PMCID: PMC4307694
5.  Objective Structured Clinical Examinations Provide Valid Clinical Skills Assessment in Emergency Medicine Education 
Introduction
Evaluation of emergency medicine (EM) learners based on observed performance in the emergency department (ED) is limited by factors such as reproducibility and patient safety. EM educators depend on standardized and reproducible assessments such as the objective structured clinical examination (OSCE). The validity of the OSCE as an evaluation tool in EM education has not been previously studied. The objective was to assess the validity of a novel management-focused OSCE as an evaluation instrument in EM education through demonstration of performance correlation with established assessment methods and case item analysis.
Methods
We conducted a prospective cohort study of fourth-year medical students enrolled in a required EM clerkship. Students enrolled in the clerkship completed a five-station EM OSCE. We used Pearson’s coefficient to correlate OSCE performance with performance in the ED based on completed faculty evaluations. Indices of difficulty and discrimination were computed for each scoring item.
Results
We found a moderate and statistically-significant correlation between OSCE score and ED performance score [r(239) =0.40, p<0.001]. Of the 34 OSCE testing items the mean index of difficulty was 63.0 (SD =23.0) and the mean index of discrimination was 0.52 (SD =0.21).
Conclusion
Student performance on the OSCE correlated with their observed performance in the ED, and indices of difficulty and differentiation demonstrated alignment with published best-practice testing standards. This evidence, along with other attributes of the OSCE, attest to its validity. Our OSCE can be further improved by modifying testing items that performed poorly and by examining and maximizing the inter-rater reliability of our evaluation instrument.
doi:10.5811/westjem.2014.11.22440
PMCID: PMC4307695
6.  Change to an Informal Interview Dress Code Improves Residency Applicant Perceptions 
Introduction
Residency interview apparel has traditionally been the dark business suit. We changed the interview dress code from a traditionally established unwritten ‘formal’ attire to an explicitly described ‘informal’ attire. We sought to assess if the change in dress code attire changed applicants’ perceptions of the residency program or decreased costs.
Methods
The authors conducted an anonymous survey of applicants applying to one emergency medicine residency program during two application cycles ending in 2012 and 2013. Applicants were asked if the change in dress code affected their perception of the program, comfort level, overall costs and how it affected their rank lists.
Results
We sent the survey to 308 interviewed applicants over two years. Of those, 236 applicants completed the survey for a combined response rate of 76.6% (236/308). Among respondents, 85.1% (200 of 235) stated they appreciated the change; 66.7% (154 of 231) stated the change caused them to worry more about what to wear. Males were more uncomfortable than females due to the lack of uniformity on the interview day (18.5% of males [25/135] vs. 7.4% of females [7/95], collapsed results p-value 0.008). A total of 27.7% (64/231) agreed that the costs were less overall. The change caused 50 of 230 (21.7%) applicants to rank the program higher on their rank list and only one applicant to rank the program lower.
Conclusion
A change to a more informal dress code resulted in more comfort and fewer costs for applicants to a single residency program. The change also resulted in some applicants placing the program higher on their rank order list.
doi:10.5811/westjem.2014.11.22982
PMCID: PMC4307696
7.  Educational Technology Improves ECG Interpretation of Acute Myocardial Infarction among Medical Students and Emergency Medicine Residents 
Introduction
Asynchronous online training has become an increasingly popular educational format in the new era of technology-based professional development. We sought to evaluate the impact of an online asynchronous training module on the ability of medical students and emergency medicine (EM) residents to detect electrocardiogram (ECG) abnormalities of an acute myocardial infarction (AMI).
Methods
We developed an online ECG training and testing module on AMI, with emphasis on recognizing ST elevation myocardial infarction (MI) and early activation of cardiac catheterization resources. Study participants included senior medical students and EM residents at all post-graduate levels rotating in our emergency department (ED). Participants were given a baseline set of ECGs for interpretation. This was followed by a brief interactive online training module on normal ECGs as well as abnormal ECGs representing an acute MI. Participants then underwent a post-test with a set of ECGs in which they had to interpret and decide appropriate intervention including catheterization lab activation.
Results
148 students and 35 EM residents participated in this training in the 2012–2013 academic year. Students and EM residents showed significant improvements in recognizing ECG abnormalities after taking the asynchronous online training module. The mean score on the testing module for students improved from 5.9 (95% CI [5.7–6.1]) to 7.3 (95% CI [7.1–7.5]), with a mean difference of 1.4 (95% CI [1.12–1.68]) (p<0.0001). The mean score for residents improved significantly from 6.5 (95% CI [6.2–6.9]) to 7.8 (95% CI [7.4–8.2]) (p<0.0001).
Conclusion
An online interactive module of training improved the ability of medical students and EM residents to correctly recognize the ECG evidence of an acute MI.
doi:10.5811/westjem.2014.12.23706
PMCID: PMC4307697
8.  Correlation of the NBME Advanced Clinical Examination in EM and the National EM M4 exams 
Introduction
Since 2011 two online, validated exams for fourth-year emergency medicine (EM) students have been available (National EM M4 Exams). In 2013 the National Board of Medical Examiners offered the Advanced Clinical Examination in Emergency Medicine (EM-ACE). All of these exams are now in widespread use; however, there are no data on how they correlate. This study evaluated the correlation between the EM-ACE exam and the National EM M4 Exams.
Methods
From May 2013 to April 2014 the EM-ACE and one version of the EM M4 exam were administered sequentially to fourth-year EM students at five U.S. medical schools. Data collected included institution, gross and scaled scores and version of the EM M4 exam. We performed Pearson’s correlation and random effects linear regression.
Results
303 students took the EM-ACE and versions 1 (V1) or 2 (V2) of the EM M4 exams (279 and 24, respectively). The mean percent correct for the exams were as follows: EM-ACE 74.8 (SD-8.83), V1 83.0 (SD-6.41), V2 78.5 (SD-7.70). Pearson’s correlation coefficient for the V1/EM-ACE was 0.51 (0.42 scaled) and for the V2/EM-ACE was 0.59 (0.41 scaled). The coefficient of determination for V1/EM-ACE was 0.72 and for V2/EM-ACE = 0.71 (0.86 and 0.49 for scaled scores). The R-squared values were 0.25 and 0.30 (0.18 and 0.13, scaled), respectively. There was significant cluster effect by institution.
Conclusion
There was moderate positive correlation of student scores on the EM-ACE exam and the National EM M4 Exams.
doi:10.5811/westjem.2014.11.24189
PMCID: PMC4307698
9.  Ultrafest: A Novel Approach to Ultrasound in Medical Education Leads to Improvement in Written and Clinical Examinations 
Introduction
Our objective was to evaluate the effectiveness of hands-on training at a bedside ultrasound (US) symposium (“Ultrafest”) to improve both clinical knowledge and image acquisition skills of medical students. Primary outcome measure was improvement in multiple choice questions on pulmonary or Focused Assessment with Sonography in Trauma (FAST) US knowledge. Secondary outcome was improvement in image acquisition for either pulmonary or FAST.
Methods
Prospective cohort study of 48 volunteers at “Ultrafest,” a free symposium where students received five contact training hours. Students were evaluated before and after training for proficiency in either pulmonary US or FAST. Proficiency was assessed by clinical knowledge through written multiple-choice exam, and clinical skills through accuracy of image acquisition. We used paired sample t-tests with students as their own controls.
Results
Pulmonary knowledge scores increased by a mean of 10.1 points (95% CI [8.9–11.3], p<0.00005), from 8.4 to a posttest average of 18.5/21 possible points. The FAST knowledge scores increased by a mean of 7.5 points (95% CI [6.3–8.7] p<0.00005), from 8.1 to a posttest average of 15.6/21. We analyzed clinical skills data on 32 students. The mean score was 1.7 pretest and 4.7 posttest of 12 possible points. Mean improvement was 3.0 points (p<0.00005) overall, 3.3 (p=0.0001) for FAST, and 2.6 (p=0.003) for the pulmonary US exam.
Conclusion
This study suggests that a symposium on US can improve clinical knowledge, but is limited in achieving image acquisition for pulmonary and FAST US assessments. US training external to official medical school curriculum may augment students’ education.
doi:10.5811/westjem.2014.11.23746
PMCID: PMC4307699
10.  13-Year-Old with Cryptic Abdominal Pain 
doi:10.5811/westjem.2014.11.24429
PMCID: PMC4307700
11.  Delayed Diagnosis of Gastric Outlet Obstruction from Bouveret Syndrome in a Young Woman 
Bouveret syndrome is a rare presentation of gastric outlet obstruction caused by a gallstone in the proximal duodenum via a bilioenteric fistula. This is an infrequent although clinically significant cause of abdominal pain, almost exclusively in the elderly. The clinical presentation is similar to that of a small bowel obstruction with abdominal pain, nausea and vomiting. Surgery or endoscopy is often required for definitive diagnosis and therapy. We describe the case of a young woman with this condition who had a delayed diagnosis in part because of her age and the rarity of the condition.
doi:10.5811/westjem.2014.10.23049
PMCID: PMC4307701
12.  Complications of New Medications 
Numerous mandibular pathologies are diagnosed in the emergency department (ED). We present the case of a woman with severe right-sided mandibular pain who was found to have a pathological fracture and osteonecrosis of the jaw (ONJ). The etiology of ONJ was found to be associated to previous use of zoledronic acid to treat osteoporosis. The aim of this case report is to discuss the etiology, diagnosis and treatment of ONJ secondary to the use of zoledronic acid and to outline a clinical condition rarely seen in the ED whose incidence might rise with the increasing use of bisphosphonates.
doi:10.5811/westjem.2014.10.23837
PMCID: PMC4307702
13.  Bilateral Inferior Shoulder Dislocation 
doi:10.5811/westjem.2015.11.24270
PMCID: PMC4307703
14.  Acute Idiopathic Compartment Syndrome of the Forearm in an Adolescent 
Acute compartment syndrome (ACS) is a condition typically associated with long bone fractures or severe trauma; however, non-traumatic etiologies also occur. We describe a case of an otherwise healthy female pediatric patient presenting with unilateral forearm pain without an inciting injury. Intracompartmental pressures of the forearm were measured and she was diagnosed with idiopathic compartment syndrome. Our goal is to encourage clinicians to consider acute compartment syndrome even in the absence of trauma.
doi:10.5811/westjem.2014.9.23019
PMCID: PMC4307704
15.  Achilles Tendon Rupture 
doi:10.5811/westjem.2014.10.24127
PMCID: PMC4307705
17.  Necrotizing Fasciitis Caused by Hypermucoviscous Klebsiella pneumoniae in a Filipino Female in North America 
Necrotizing fasciitis caused by Klebsiella pneumoniae has been described in Southeast Asia, but has only recently begun to emerge in North America. The hypermucoviscous strain of K. pneumoniae is a particularly virulent strain known to cause devastatingly invasive infections, including necrotizing fasciitis. Here we present the first known case of necrotizing fasciitis caused by hypermucoviscous K. pneumoniae in North America.
doi:10.5811/westjem.2014.11.23599
PMCID: PMC4307707
19.  Persistent Pain After Lithotripsy 
doi:10.5811/westjem.2014.11.24467
PMCID: PMC4307709
20.  Survival from Cervical Necrotizing Fasciitis 
Cervical necrotizing fasciitis (CNF) is an uncommon, yet clinically significant infection that rapidly progresses to involve the deep neck spaces. Early recognition and aggressive surgical intervention and debridement are important, as this disease is associated with a high morbidity and mortality. In this report, we present a case of CNF and descending mediastinitis from a non-odontogenic source in a patient presenting with neck swelling and odynophagia.
doi:10.5811/westjem.2014.12.21553
PMCID: PMC4307710
22.  Bedside Echocardiography for Undifferentiated Hypotension: Diagnosis of a Right Heart Thrombus 
A free-floating right heart thrombus is often a harbinger of a massive pulmonary embolism and must be diagnosed and treated rapidly in order to avoid significant adverse sequelae. We present the case of an 84-year-old female who presented with two days of dyspnea and was hypotensive on arrival. Bedside ultrasound was performed by the emergency physician and showed a large, mobile right heart thrombus leading to immediate administration of a thrombolytic. In this case, bedside ultrasound was utilized to help further delineate clinical care in a progressively worsening patient, leading to a potentially lifesaving treatment.
doi:10.5811/westjem.2014.12.23262
PMCID: PMC4307712
23.  Feasibility of Tablet Computer Screening for Opioid Abuse in the Emergency Department 
Introduction
Tablet computer-based screening may have the potential for detecting patients at risk for opioid abuse in the emergency department (ED). Study objectives were a) to determine if the revised Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), a 24-question previously paper-based screening tool for opioid abuse potential, could be administered on a tablet computer to an ED patient population; b) to demonstrate that >90% of patients can complete the electronic screener without assistance in <5 minutes and; c) to determine patient ease of use with screening on a tablet computer.
Methods
This was a cross-sectional convenience sample study of patients seen in an urban academic ED. SOAPP®-R was programmed on a tablet computer by study investigators. Inclusion criteria were patients ages ≥18 years who were being considered for discharge with a prescription for an opioid analgesic. Exclusion criteria included inability to understand English or physical disability preventing use of the tablet.
Results
93 patients were approached for inclusion and 82 (88%) provided consent. Fifty-two percent (n=43) of subjects were male; 46% (n=38) of subjects were between 18–35 years, and 54% (n=44) were >35 years. One hundred percent of subjects completed the screener. Median time to completion was 148 (interquartile range 117.5–184.3) seconds, and 95% (n=78) completed in <5 minutes. 93% (n=76) rated ease of completion as very easy.
Conclusions
It is feasible to administer a screening tool to a cohort of ED patients on a tablet computer. The screener administration time is minimal and patient ease of use with this modality is high.
doi:10.5811/westjem.2014.11.23316
PMCID: PMC4307713
24.  Half-dose Alteplase for Sub-massive Pulmonary Embolism Directed by Emergency Department Point-of-care Ultrasound 
This report describes a patient with sub-massive pulmonary embolism (PE) who was successfully treated with half-dose thrombolytics guided by the use of point-of-care (POC) ultrasound. In this case, POC ultrasound was the only possible imaging since computed tomography was contraindicated. POC ultrasound demonstrated a deep vein thrombosis and evidence of cardiac strain. In situations or locations where definitive imaging is unobtainable, POC ultrasound can help diagnose submassive PE and direct the use of half-dose tissue plasminogen activator.
doi:10.5811/westjem.2014.12.24130
PMCID: PMC4307714
25.  Improving Door-to-balloon Time by Decreasing Door-to-ECG time for Walk-in STEMI Patients 
Introduction
The American Heart Association/American College of Cardiology guidelines recommend rapid door-to-electrocardiography (ECG) times for patients with ST-segment elevation myocardial infarction (STEMI). Previous quality improvement research at our institution revealed that we were not meeting this benchmark for walk-in STEMI patients. The objective is to investigate whether simple, directed changes in the emergency department (ED) triage process for potential cardiac patients could decrease door-to-ECG times and secondarily door-to-balloon times.
Methods
We conducted an interventional study at a large, urban, public teaching hospital from April 2010 to June 2012. All patients who walked into the ED with a confirmed STEMI were enrolled in the study. The primary intervention involved creating a chief complaint-based “cardiac triage” designation that streamlined the evaluation of potential cardiac patients. A secondary intervention involved moving our ECG technician and ECG station to our initial triage area. The primary outcome measure was door-to-ECG time and the secondary outcome measure was door-to-balloon time.
Results
We enrolled 91 walk-in STEMI patients prior to the intervention period and 141 patients after the invention. We observed statistically significant reductions in door-to-ECG time (43±93 to 30±72 minutes, median 23 to 14 minutes p<0.01), ECG-to-activation time (87±134 to 52±82 minutes, median 43 to 31 minutes p<0.01), and door-to-balloon time (134±146 to 84±40 minutes, median 85 -75 minutes p=0.03).
Conclusion
By creating a chief complaint-based cardiac triage protocol and by streamlining ECG completion, walk-in STEMI patients are systematically processed through the ED. This is not only associated with a decrease in door-to-balloon time, but also a decrease in the variability of the time sensitive intervals of door-to-ECG and ECG-to-balloon time.
doi:10.5811/westjem.2014.10.23277
PMCID: PMC4307715

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