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1.  Complete Ventricular Asystole in a Patient with Altered Mental Status 
Patients who present with recurrent syncope are at risk for having underlying conduction disease, which may worsen if not promptly recognized and treated. We describe a patient who initially presented to a Mexican clinic with recurrent syncope and an electrocardiogram that showed complete heart block. After being transferred to our emergency department, he deteriorated into complete ventricular asystole with preserved atrial function and required placement of a transvenous cardiac pacemaker.
doi:10.5811/westjem.2013.10.18884
PMCID: PMC3966435  PMID: 24672602
2.  4,871 Emergency Airway Encounters by Air Medical Providers: A Report of the Air Transport Emergency Airway Management (NEAR VI: “A-TEAM”) Project 
Introduction
Pre-hospital airway management is a key component of resuscitation although the benefit of pre-hospital intubation has been widely debated. We report a large series of pre-hospital emergency airway encounters performed by air-transport providers in a large, multi-state system.
Methods
We retrospectively reviewed electronic intubation flight records from an 89 rotorcraft air medical system from January 01, 2007, through December 31, 2009. We report patient characteristics, intubation methods, success rates, and rescue techniques with descriptive statistics. We report proportions with 95% confidence intervals and binary comparisons using chi square test with p-values <0.05 considered significant.
Results
4,871 patients had active airway management, including 2,186 (44.9%) medical and 2,685 (55.1%) trauma cases. There were 4,390 (90.1%) adult and 256 (5.3%) pediatric (age ≤ 14) intubations; 225 (4.6%) did not have an age recorded. 4,703 (96.6%) had at least one intubation attempt. Intubation was successful on first attempt in 3,710 (78.9%) and was ultimately successful in 4,313 (91.7%). Intubation success was higher for medical than trauma patients (93.4% versus 90.3%, p=0.0001 JT test). 168 encounters were managed primarily with an extraglottic device (EGD). Cricothyrotomy was performed 35 times (0.7%) and was successful in 33. Patients were successfully oxygenated and ventilated with an endotracheal tube, EGD, or surgical airway in 4809 (98.7%) encounters. There were no reported deaths from a failed airway.
Conclusion
Airway management, predominantly using rapid sequence intubation protocols, is successful within this high-volume, multi-state air-transport system.
doi:10.5811/westjem.2013.11.18549
PMCID: PMC3966436  PMID: 24672610
3.  Onset and Duration of Intravenous and Intraosseous Rocuronium in Swine 
Introduction
The intraosseous (IO) route has become a popular method to gain access to the peripheral circulation in emergency situations. Despite little supporting data, it is generally believed that IO absorption is immediate and equivalent to the intravenous (IV) route. It is important to determine if rocuronium can effectively be administered by the IO route. The aim of the study was to determine and compare the onset and duration of rocuronium when administered via the IO and IV routes in a normovolemic pig model.
Methods
We recorded electromyographic (EMG) data following tibial IO and peripheral IV administration of rocuronium (1.2 mg/kg) in 10 swine weighing between 56 and 71 Kg. We transformed data were transformed to percent of baseline, determined onset and recovery characteristics.
Results
The onset EMG-time profiles for IO and IV administration were very similar: tibial IO compared to IV administration did not statistically alter the onset of paralysis. The IO group took statistically longer than the IV group to return to 50 (p=0.042), 75 (p=0.034) and 95 (p=0.036) percent of baseline activity.
Conclusion
The duration of effect is statistically longer after IO administration but is more of an academic interest than a clinical concern. The results of this study suggest that rocuronium can effectively be administered via the IO route without the need for dose adjustments.
doi:10.5811/westjem.2013.9.14484
PMCID: PMC3966437  PMID: 24672619
4.  Ambulatory Cardiac Monitoring for Discharged Emergency Department Patients with Possible Cardiac Arrhythmias 
Introduction
Many emergency department (ED) patients have symptoms that may be attributed to arrhythmias, necessitating outpatient ambulatory cardiac monitoring. Consensus is lacking on the optimal duration of monitoring. We describe the use of a novel device applied at ED discharge that provides continuous prolonged cardiac monitoring.
Methods
We enrolled discharged adult ED patients with symptoms of possible cardiac arrhythmia. A novel, single use continuous recording patch (Zio®Patch) was applied at ED discharge. Patients wore the device for up to 14 days or until they had symptoms to trigger an event. They then returned the device by mail for interpretation. Significant arrhythmias are defined as: ventricular tachycardia (VT) ≥4 beats, supraventricular tachycardia (SVT) ≥4 beats, atrial fibrillation, ≥3 second pause, 2nd degree Mobitz II, 3rd degree AV Block, or symptomatic bradycardia.
Results
There were 174 patients were enrolled and all mailed back their devices. The average age was 52.2 (± 21.0) years, and 55% were female. The most common indications for device placement were palpitations 44.8%, syncope 24.1% and dizziness 6.3%. Eighty-three patients (47.7%) had ≥1 arrhythmias and 17 (9.8%) were symptomatic at the time of their arrhythmia. Median time to first arrhythmia was 1.0 days (IQR 0.2–2.8) and median time to first symptomatic arrhythmia was 1.5 days (IQR 0.4–6.7). 93 (53.4%) of symptomatic patients did not have any arrhythmia during their triggered events. The overall diagnostic yield was 63.2%
Conclusion
The Zio®Patch cardiac monitoring device can efficiently characterize symptomatic patients without significant arrhythmia and has a higher diagnostic yield for arrhythmias than traditional 24–48 hour Holter monitoring. It allows for longer term monitoring up to 14 days.
doi:10.5811/westjem.2013.11.18973
PMCID: PMC3966438  PMID: 24672611
5.  High-pressure Injection Injury with Molten Aluminum 
doi:10.5811/westjem.2013.10.19443
PMCID: PMC3966439  PMID: 24672592
6.  Prospective Analysis of Single Operator Sonographic Optic Nerve Sheath Diameter Measurement for Diagnosis of Elevated Intracranial Pressure 
Introduction
The accurate diagnosis of elevated intracranial pressure (eICP) in the emergent setting is a critical determination that presents significant challenges. Several studies show correlation of sonographic optic nerve sheath diameter (ONSD) to eICP, while others show high inter-observer variability or marginal performance with less experienced sonographers. The objective of our study is to assess the ability of bedside ultrasound measurement of ONSD to identify the presence of eICP when performed by a single experienced sonographer. We hypothesize that ONSD measurement is sensitive and specific for detecting eICP and can be correlated with values obtained by external ventricular device (EVD).
Methods
This was a prospective blinded observational study conducted in a neurocritical care unit of a level 1 trauma center. ONSD measurement was performed on a convenience sample of 27 adult patients who required placement of an invasive intracranial monitor as part of their clinical care. One certified sonographer/physician performed all ultrasounds within 24 hours of placement of EVD. The sonographer was blinded to the ICP recorded by invasive monitor at the time of the scan. A mean ONSD value of ≥5.2 mm was taken as positive.
Results
The sonographer performed 27 ocular ultrasounds on individual patients. Six (22%) of these patients had eICP (EVD measurement of >20 mmHg). Spearman rank correlation coefficient of ONSD and ICP was 0.408 (p=0.03), demonstrating a moderate positive correlation. A ROC curve was created to determine the optimal cut off value to distinguish an eICP greater than 20 mmHg. The area under the receiver operator characteristic curve was 0.8712 (95% confidence interval [CI]=0.67 to 0.96). ONSD ≥5.2 mm was a good predictor of eICP (>20 mmHg) with a sensitivity of 83.3% (95% CI=35.9% to 99.6%) and specificity of 100% (95% CI=84.6% to 100%).
Conclusion
While the study suggests ONSD measurements performed by a single skilled operator may be both sensitive and specific for detecting eICP, confirmation in a much larger sample is needed. Ocular ultrasound may provide additional non-invasive means of assessing eICP.
doi:10.5811/westjem.2013.9.16191
PMCID: PMC3966440  PMID: 24672615
7.  Improving Bariatric Patient Transport and Care with Simulation 
Introduction
Obesity is prevalent in the United States. Obese patients have physiologic differences from non-obese individuals. Not only does transport and maintenance of these patients require use of specialized equipment, but it also requires a distinct skill set and knowledge base. To date, there is no literature investigating simulation as a model for educating pre-hospital providers in the care of bariatric patients. The purpose of this study was to determine if a 3-hour educational course with simulation could improve paramedics’ knowledge and confidence of bariatric procedures and transport. This study also examined if prior experience with bariatric transport affected training outcomes.
Methods
Our study took place in August 2012 during paramedic training sessions. Paramedics completed a pre- and post-test that assessed confidence and knowledge and provided information on previous experience. They had a 30-minute didactic and participated in 2 20-minute hands-on skills portions that reviewed procedural issues in bariatric patients, including airway procedures, peripheral venous and intraosseous access, and cardiopulmonary resuscitation. Study participants took part in one of two simulated patient encounters. Paramedics were challenged with treating emergent traumatic and/or medical conditions, as well as extricating and transporting bariatric patients. Each group underwent a debriefing of the scenario immediately following their case. We measured confidence using a 5-point Likert-type response scale ranging from 1 (strongly disagree) to 5 (strongly agree) on a 7-item questionnaire. We assessed knowledge with 12 multiple choice questions. Paired-sample t-tests were used to compare pre- and post-simulation confidence and knowledge with a significance level of p≤0.05. We used analysis of covariance to examine the effect of previous experiences on pre-and post-educational activity confidence and knowledge with a significance level of p ≤0.05. Proportions and 95% confidence intervals are presented as appropriate. We determined the magnitude of significant pre-post differences with Cohen’s d. We assessed scale reliability using Cronbach’s alpha and was found to be reliable with scores of 0.83 and 0.88 across pre- and post-test responses, respectively.
Results
Participants exhibited a significant increase in confidence in performing procedures (p<0.01) and knowledge of bariatric patient management (p<0.001) after the simulation. The current study also found an increase in knowledge of transport, vascular access/circulation and airway management (p<0.001). Participant background showed no effects on these changes.
Conclusion
This study suggests that simulation paired with a didactic is an effective method of education for paramedics caring for and transporting bariatric patients. The data show a significant increase in knowledge and confidence with a 3-hour training session, irrespective of previous training or experience with bariatric patients. This is the first study of its kind to apply simulation training for the pre-hospital care of bariatric patients.
doi:10.5811/westjem.2013.12.18855
PMCID: PMC3966441  PMID: 24672612
8.  Lemierre’s Syndrome 
doi:10.5811/westjem.2013.12.20418
PMCID: PMC3966442  PMID: 24672595
9.  Hospital Factors Impact Variation in Emergency Department Length of Stay more than Physician Factors 
Introduction
To analyze the correlation between the many different emergency department (ED) treatment metric intervals and determine if the metrics directly impacted by the physician correlate to the “door to room” interval in an ED (interval determined by ED bed availability). Our null hypothesis was that the cause of the variation in delay to receiving a room was multifactorial and does not correlate to any one metric interval.
Methods
We collected daily interval averages from the ED information system, Meditech©. Patient flow metrics were collected on a 24-hour basis. We analyzed the relationship between the time intervals that make up an ED visit and the “arrival to room” interval using simple correlation (Pearson Correlation coefficients). Summary statistics of industry standard metrics were also done by dividing the intervals into 2 groups, based on the average ED length of stay (LOS) from the National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.
Results
Simple correlation analysis showed that the doctor-to-discharge time interval had no correlation to the interval of “door to room (waiting room time)”, correlation coefficient (CC) (CC=0.000, p=0.96). “Room to doctor” had a low correlation to “door to room” CC=0.143, while “decision to admitted patients departing the ED time” had a moderate correlation of 0.29 (p <0.001). “New arrivals” (daily patient census) had a strong correlation to longer “door to room” times, 0.657, p<0.001. The “door to discharge” times had a very strong correlation CC=0.804 (p<0.001), to the extended “door to room” time.
Conclusion
Physician-dependent intervals had minimal correlation to the variation in arrival to room time. The “door to room” interval was a significant component to the variation in “door to discharge” i.e. LOS. The hospital-influenced “admit decision to hospital bed” i.e. hospital inpatient capacity, interval had a correlation to delayed “door to room” time. The other major factor affecting department bed availability was the “total patients per day.” The correlation to the increasing “door to room” time also reflects the effect of availability of ED resources (beds) on the patient evaluation time. The time that it took for a patient to receive a room appeared more dependent on the system resources, for example, beds in the ED, as well as in the hospital, than on the physician.
doi:10.5811/westjem.2013.12.6860
PMCID: PMC3966443  PMID: 24672604
10.  Popliteal Artery Injury Associated with Blunt Trauma to the Knee without Fracture or Dislocation 
Popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. Concern about arterial injury and early recognition of the possibility of arterial injury is crucial for the salvage of the extremity. This article provides an outline of the diagnostic challenges related to these rare vascular injuries and emphasizes the necessity for a high level of suspicion, even in the absence of a significant penetrating injury, knee dislocation, fracture, or high-velocity trauma mechanism. The importance of a detailed vascular examination of a blunt trauma patient is emphasized.
doi:10.5811/westjem.2013.12.18223
PMCID: PMC3966444  PMID: 24672601
11.  Emergency Department Crowding and Loss of Medical Licensure: A New Risk of Patient Care in Hallways 
We report the case of a 32-year-old male recently diagnosed with type 2 diabetes treated at an urban university emergency department (ED) crowded to 250% over capacity. His initial symptoms of shortness of breath and feeling ill for several days were evaluated with chest radiograph, electrocardiogram (EKG), and laboratory studies, which suggested mild diabetic ketoacidosis. His medical care in the ED was conducted in a crowded hallway. After correction of his metabolic abnormalities he felt improved and was discharged with arrangements made for outpatient follow-up. Two days later he returned in cardiac arrest, and resuscitation efforts failed. The autopsy was significant for multiple acute and chronic pulmonary emboli but no coronary artery disease. The hospital settled the case for $1 million and allocated major responsibility to the treating emergency physician (EP). As a result the state medical board named the EP in a disciplinary action, claiming negligence because the EKG had not been personally interpreted by that physician. A formal hearing was conducted with the EP’s medical license placed in jeopardy. This case illustrates the risk to EPs who treat patients in crowded hallways, where it is difficult to provide the highest level of care. This case also demonstrates the failure of hospital administration to accept responsibility and provide resources to the ED to ensure patient safety.
doi:10.5811/westjem.2013.11.18645
PMCID: PMC3966445  PMID: 24672599
12.  Delayed Presentation of Deep Sternal Wound Infection 
Deep sternal wound infections (DSWI) are infections of the sternum, mediastinum, or the muscle, fascia and soft tissue that overlie the sternum, typically occurring within a month of cardiac surgery. They are infrequent though severe complications of cardiac surgery. Diagnosis is made by the clinical presentation of fever, chest pain, or sternal instability in the setting of wound drainage, positive wound cultures, or chest radiographic findings. We describe the case of an elderly man presenting 6 months after cardiac surgery with DSWI. Due to the atypical nature of such a late presentation, definitive therapy was delayed. Given a severely ill patient with multiple risk factors for poor wound healing, the clinician must maintain a high index of suspicion for DSWI despite a delayed presentation.
doi:10.5811/westjem.2013.11.19344
PMCID: PMC3966446  PMID: 24672598
13.  Impact of an Abbreviated Cardiac Enzyme Protocol to Aid Rapid Discharge of Patients with Cocaine-associated Chest Pain in the Clinical Decision Unit 
Introduction
In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9–12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain.
Methods
We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge.
Results
There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0–5.1%; 95% CI, 0–3.6%).
Conclusion
Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.
doi:10.5811/westjem.2013.11.19232
PMCID: PMC3966447  PMID: 24672608
14.  The Ethics of the Missing Straw 
This case report details the emergency department course of a 34 year-old female who presented with abdominal pain and vaginal bleeding after reportedly falling one week earlier. She was subsequently found to have a drinking straw within her uterus next to an eight week-old live intrauterine pregnancy on ultrasound. This case report and discussion reviews the literature on retained foreign bodies in pregnancy while addressing the added complications of an evasive patient and a difficult consultant with significant intra-specialty disagreement.
doi:10.5811/westjem.2013.12.19452
PMCID: PMC3966448  PMID: 24672597
15.  Visual Estimation of Bedside Echocardiographic Ejection Fraction by Emergency Physicians 
Introduction
The objective of this study was to determine whether bedside visual estimates of left ventricular systolic function (LVSF) by emergency physicians (EP) would agree with quantitative measurement of LVSF by the modified Simpson’s method (MSM), as recommended by the American Society of Echocardiography.
Methods
After limited focused training, 2 trained EPs performed bedside echocardiography (BECH) procedures s between January and June 2012 to prospectively evaluate patients presenting to the emergency department (ED) with dyspnea. EPs categorized their visually estimated ejection fractions (VEF) as either low or normal. Formal echocardiography were ordered and performed by an experienced cardiologist using the MSM and accepted as the criterion standard. We compared BECH results for each EP using chi-squared testing and performed correlation analysis by Pearson correlation coefficient.
Results
Of the 146 enrolled patients with dyspnea, 13 were excluded and 133 were included in the study. Comparison of EPs vs. cardiologist’s estimate of ejection fraction yielded a Pearson’s correlation coefficient of 0.77 (R, p<0.0001) and 0.78 (R, p<0.0001). Calculated biserial correlations using point-biserial correlation and z-scores were 1 (rb, p<0.0001) for both EPs. The agreement between EPs and the cardiologist was 0.861 and 0.876, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and the positive and negative likelihood ratios for each physician were 98.7–98.7%, 86.2–87.9%, 0.902–0.914, 0.980–0.981, 7.153–8.175, 0.015–0.015, respectively.
Conclusion
EPs with a focused training in limited BECH can assess LVSF accurately in the ED by visual estimation.
doi:10.5811/westjem.2013.9.16185
PMCID: PMC3966449  PMID: 24672616
16.  Incarcerated Diaphragmatic Hernia with Bowel Perforation Presenting as a Tension Pneumothorax 
We present an interesting case of a patient with a previously known diaphragmatic hernia in which the colon became incarcerated, ischemic and finally perforated. She had no prior history of abdominal pain or vomiting, yet she presented with cardiovascular collapse. She was quickly diagnosed with a tension pneumothorax and treated accordingly. To our knowledge, this is the only case report of a tension pneumothorax associated with perforated bowel that was not in the setting of trauma or colonoscopy.
doi:10.5811/westjem.2013.10.19034
PMCID: PMC3966450  PMID: 24672600
17.  Diagnosis of Fournier’s Gangrene on Bedside Ultrasound 
doi:10.5811/westjem.2013.10.19476
PMCID: PMC3966451  PMID: 24672593
18.  Impact of Decontamination Therapy on Ultrasound Visualization of Ingested Pills 
Introduction
Acute toxic ingestion is a common cause of morbidity and mortality. Emergency physicians (EP) caring for overdose (OD) patients are often required to make critical decisions with incomplete information. Point of care ultrasound (POCUS) may have a role in assisting EPs manage OD patients. We evaluated the impact of different liquid adjuncts used for gastric decontamination on examiners’ ability to identify the presence of tablets using POCUS, and assessed examiners’ ability to quantify the numbers of tablets in a simulated massive OD.
Methods
This prospective, blinded, pilot study was performed at an academic emergency department. Study participants were volunteer resident and staff EPs trained in POCUS. Five nontransparent, sealed bags were prepared with the following contents: 1 liter (L) of water, 1 L of water with 50 regular aspirin (ASA) tablets, 1 L of water with 50 enteric-coated aspirin tablets (ECA), 1 L of polyethylene glycol (PEG) with 50 ECA, and 1 L of activated charcoal (AC) with 50 ECA. After performing POCUS on each of the bags using a 10-5 MHz linear array transducer, participants completed a standardized questionnaire composed of the following questions: (1) Were pills present? YES/NO; (2) If tablets were identified, estimate the number (1–10, 11–25, >25). We used a single test on proportions using the binomial distribution to determine if the number of EPs who identified tablets differed from 50% chance. For those tablets identified in the different solutions, another test on proportions was used to determine whether the type of solution made a difference. Since 3 options were available, we used a probability of 33.3%.
Results
Thirty-seven EPs completed the study. All (37/37) EP’s correctly identified the absence of tablets in the bag containing only water, and the presence of ECA in the bags containing water and PEG. For Part 2 of the study, most participants - 25/37 (67.5%) using water, 23/37 (62.1%) using PEG, and all 37 (100%) using AC - underestimated the number of ECA pills in solution by at least 50%.
Conclusion
There may be a potential role for POCUS in the evaluation of patients suspected of acute, massive ingested OD. EPs accurately identified the presence of ECA in water and PEG, but underestimated the number of tablets in all tested solutions.
doi:10.5811/westjem.2013.10.18112
PMCID: PMC3966452  PMID: 24672607
19.  Emergency Department Length of Stay: Accuracy of Patient Estimates 
Introduction
Managing a patient’s expectations in the emergency department (ED) environment is challenging. Previous studies have identified several factors associated with ED patient satisfaction. Lengthy wait times have shown to be associated with dissatisfaction with ED care. Understanding that patients are inaccurate at their estimation of wait time, which could lead to lower satisfaction, provides administrators possible points of intervention to help improve accuracy of estimation and possibly satisfaction with the ED. This study was undertaken to examine the accuracy of patient estimates of time periods in an ED and identify factors associated with accuracy.
Method
In this prospective convenience sample survey at UTMC ED, we collected data between March and July 2012. Outcome measures included duration of each phase of ED care and patient estimates of these time periods.
Results
Among 309 participants, the majority underestimated the total length of stay (LOS) in the ED (median difference −7 minutes (IQR −29-12)). There was significant variability in ED LOS (median 155 minutes (IQR 75–240)). No significant associations were identified between accuracy of time estimates and gender, age, race, or insurance status. Participants with longer ED LOS demonstrated lower patient satisfaction scores (p<0.001).
Conclusion
Patients demonstrated inaccurate time estimates of ED treatment times, including total LOS. Patients with longer ED LOS had lower patient satisfaction scores.
doi:10.5811/westjem.2013.9.15816
PMCID: PMC3966453  PMID: 24672606
20.  The Effect of Compressor-administered Defibrillation on Peri-shock Pauses in a Simulated Cardiac Arrest Scenario 
Introduction
Coordination of the tasks of performing chest compressions and defibrillation can lead to communication challenges that may prolong time spent off the chest. The purpose of this study was to determine whether defibrillation provided by the provider performing chest compressions led to a decrease in peri-shock pauses as compared to defibrillation administered by a second provider, in a simulated cardiac arrest scenario.
Methods
This was a randomized, controlled study measuring pauses in chest compressions for defibrillation in a simulated cardiac arrest model. We approached hospital providers with current CPR certification for participation between July, 2011 and October, 2011. Volunteers were randomized to control (facilitator-administered defibrillation) or experimental (compressor-administered defibrillation) groups. All participants completed one minute of chest compressions on a mannequin in a shockable rhythm prior to administration of defibrillation. We measured and compared pauses for defibrillation in both groups.
Results
Out of 200 total participants, we analyzed data from 197 defibrillations. Compressor-initiated defibrillation resulted in a significantly lower pre-shock hands-off time (0.57 s; 95% CI: 0.47–0.67) compared to facilitator-initiated defibrillation (1.49 s; 95% CI: 1.35–1.64). Furthermore, compressor-initiated defibrillation resulted in a significantly lower peri-shock hands-off time (2.77 s; 95% CI: 2.58–2.95) compared to facilitator-initiated defibrillation (4.25 s; 95% CI: 4.08–4.43).
Conclusion
Assigning the responsibility for shock delivery to the provider performing compressions encourages continuous compressions throughout the charging period and decreases total time spent off the chest. However, as this was a simulation-based study, clinical implementation is necessary to further evaluate these potential benefits.
doi:10.5811/westjem.2013.9.18007
PMCID: PMC3966454  PMID: 24672620
21.  Staff Perceptions of an On-site Clinical Pharmacist Program in an Academic Emergency Department after One Year 
Introduction
Emergency department clinical pharmacists (EPh) serve a relatively new clinical role in emergency medicine. New EPh may still face barriers prior to working in the emergency department (ED), including staff acceptance. We aimed to assess staff perceptions of a university hospital EPh program 1 year after implementation.
Methods
We sent an electronic survey consisting of 7 multiple-choice questions, 17 5-point Likert-scale questions, and 1 free-text comment section to ED providers and nurses. The qualitatively validated survey assessed staff’s general perceptions of the EPh and their clinical work.
Results
We received responses from 14 attending physicians, 34 emergency medicine residents, 5 mid-level providers, and 51 nurses (80% response rate). Overall, the ED staff strongly supported the presence of an EPh. All of the respondents consulted the EPh at least once in their previous 5 ED shifts. Most respondents (81%) felt the EPh’s availability for general consultation and aid during resuscitations served as the major contribution to medication and patient safety. The participants also expressed that they were more likely to consult a pharmacist when they were located in the ED, as opposed to having to call the main pharmacy.
Conclusion
The EPh model of practice at our institution provides valuable perceived benefit to ED providers.
doi:10.5811/westjem.2013.11.18069
PMCID: PMC3966455  PMID: 24672613
22.  Cardiac Sarcoma: Unusual Cause of Intracardiac Contrast Filling Defect 
A 28-year-old female was transferred to the emergency department from her physician’s office for further evaluation of tachycardia. She was being seen for a recent illness which included nausea, vomiting, diarrhea and fevers. The patient endorsed fatigue, dyspnea on exertion, and extremity edema. She had no chest pain or cough. Exam revealed a pale, fatigued, mildly ill-appearing female with bilateral lower extremity edema and diminished breath sounds on the right. Chest radiograph revealed a large right pleural effusion (Figure 1). Computed tomographic angiography of the chest was performed (Figure 2).
doi:10.5811/westjem.2013.12.20576
PMCID: PMC3966456  PMID: 24672594
23.  Splenic Laceration and Pulmonary Contusion Injury From Bean Bag Weapon 
doi:10.5811/westjem.2013.10.19900
PMCID: PMC3966457  PMID: 24672591
24.  Urinary Metabolomic Analysis to Detect Changes After Intravenous, Non-ionic, Low Osmolar Iodinated Radiocontrast for Computerized Tomographic Imaging 
Introduction
Contrast-induced nephropathy is a result of injury to the proximal tubules caused by oxidative stress and ischemia. Metabolomics is a novel technique that has been used to identify renal damage from drug toxicities. The objective of this study is to analyze the metabolic changes in the urine after dosing with intravenous (IV) contrast for computed tomograph (CT) of the chest
Methods
A convenience sample of patients undergoing a chest CT with IV contrast who had at least one of the following: age ≥50 years, diabetes, heart failure, chronic kidney disease, coronary artery disease, or diastolic blood pressure >90 mmHg -- were eligible for enrollment. Urine samples were collected prior to imaging and 4–6 hours post imaging. Samples underwent gas chromography/mass spectrometry profiling. We measured peak metabolite values and log transformed data. Paired T tests were calculated. We used significance analysis of microarrays (SAM) to determine the most significant metabolites.
Results
The cohort comprised 14 patients with matched samples; 9/14 (64.3) were males, and the median age was 61 years (IQR 50–68). A total of 158 metabolites were identified. Using SAM we identified 9 metabolites that were identified as significant using a delta of 1.6.
Conclusion
Changes in urinary metabolites are present soon after contrast administration. This change in urinary metabolites may be potential early identifiers of contrast-induced nephropathy and could identify patients at high-risk for developing this condition.
doi:10.5811/westjem.11.15343
PMCID: PMC3966458  PMID: 24672603
25.  Dysuria in the Emergency Department: Missed Diagnosis of Chlamydia trachomatis 
Introduction
The clinical presentation of genital Chlamydia trachomatis infection (chlamydia) in women is often indistinguishable from a urinary tract infection. While merited in the setting of dysuria, emergency department (ED) clinicians do not routinely test for chlamydia in women. The primary aim of our study was to evaluate the frequency of chlamydia testing among women presenting to the ED with dysuria.
Methods
We conducted a retrospective chart review of women 19–25 years of age presenting with dysuria to an urban ED and who had been coded with urinary tract infection (UTI) as their primary diagnosis (ICD-9 599.0) from October 2005 to March 2011. We excluded women who were pregnant, had underlying anatomical or neurological urinary system pathology, had continuation of symptoms from UTI or a sexually transmitted infection (STI) diagnosed elsewhere, or were already on antibiotics for a UTI or STI. We identified the rates of sexual history screening, pelvic examination and chlamydia assay testing and evaluated predictors using univariate and multivariate analyses.
Results
Of 280 women with dysuria and a UTI diagnosis, 17% were asked about their sexual history, with 94% reporting recent sexual activity. Pelvic examination was performed in 23%. We were unable to determine the overall chlamydia prevalence as only 20% of women in the cohort were tested. Among the 20% of women tested for chlamydia infection, 21% tested positive. Only 42% of chlamydia-positive women were prescribed treatment effective for chlamydia (azithromycin or doxycycline) at their visit; the remaining were prescribed UTI treatment not effective against chlamydia. Predictors of sexual history screening included vaginal bleeding (OR 5.4, 95% CI=1.5 to 19.6) and discharge (OR 2.8, 95% CI=1.1 to 6.9). Predictors of a pelvic examination being performed included having a complaint of vaginal discharge (OR 11.8, 95% CI=4.2 to 32.9), a sexual history performed (OR 2.5, 95% CI=1.1 to 5.8), abdominal pain (OR 2.2, 95% CI=1.1 to 4.4), or pelvic pain (OR 15.3, 95% CI=2.5 to 92.2); a complaint of urinary frequency was associated with a pelvic examination not being performed (OR 0.34, 95% CI=0.13 to 0.86).
Conclusion
Sexual histories, pelvic examinations, and chlamydia testing were not performed in the majority of women presenting with dysuria and diagnosed with UTI in the ED. The performance of a sexual history along with the availability of self-administered vaginal swab and first-void urine-based chlamydia tests may increase identification of chlamydia infection in women with dysuria.
doi:10.5811/westjem.2013.12.18989
PMCID: PMC3966459  PMID: 24672617

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