Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Objective: To estimate the sensitivity and specificity of emergency department (ED) ultrasound for the detection of solid organ injury following blunt abdominal trauma.

Methods: A prospective cohort study performed in the ED of an urban Level I trauma center on patients who sustained blunt abdominal trauma. Following initial standard trauma evaluation, patients underwent a secondary ultrasound examination performed specifically to identify injury to the liver or spleen, followed by computed tomography (CT) scan of the abdomen. Ultrasound examinations were performed by emergency medicine residents or attending physicians experienced in the use of ultrasound for detecting hemoperitoneum. Ultrasonographers prospectively determined the presence or absence of liver or spleen injury. CT findings were used as the criterion standard to evaluate the ultrasound results.

Results: From July 1998 through June 1999, 152 patients underwent secondary ultrasound examination and CT. Of the 152 patients, nine (6%) had liver injuries and 10 (7%) had spleen injuries. Ultrasound correctly detected only one of the liver injuries for a sensitivity of 11% (95% CI: 0%-48%) and a specificity of 98% (95% CI: 94%-100%). Ultrasound correctly detected eight spleen injuries for a sensitivity of 80% (95% CI: 44%-98%) and a specificity of 99% (95% CI: 95%-100%).

Conclusion: Emergency ultrasound is not sensitive or specific for detecting liver or spleen injuries following blunt abdominal trauma.

[WestJEM. 2009;10:1-5.]

A controversial term first described by Saunders and Harbaugh1 in 1984, Second Impact Syndrome (SIS) consists of two events. Typically, it involves an athlete suffering post-concussive symptoms following a head injury.2 If, within several weeks, the athlete returns to play and sustains a second head injury, diffuse cerebral swelling, brain herniation, and death can occur. SIS can occur with any two events involving head trauma. While rare, it is devastating in that young, healthy patients may die within a few minutes. Emergency physicians should be aware of this syndrome and counsel patients and their parents concerning when to allow an athlete to return to play. Furthermore, we present guidelines for appropriate follow up and evaluation by a specialist when necessary.

[WestJEM. 2009;10:6-10.]

[WestJEM. 2009;10:11-17.]

[WestJEM. 2009;10:18.]

[WestJEM. 2009;10:19.]

[WestJEM. 2009;10:20.]

The immense body of knowledge that emergency medicine (EM) encompasses is constantly growing and ever changing. Textbooks build a strong foundation for the EM resident, but journal articles critical for modifying and improving EM practices are equally important for a well-rounded education. Determining which journal articles are vital to an EM residency education is a challenge. Lacking a formalized list of key articles available to EM residents and realizing that a list of articles without a guide may be difficult and confusing for novice readers, we created the “Colorado Compendium”: a recommended reading list, limited to 100 articles with accompanying summaries, tailored to emergency medicine residents.

[WestJEM. 2009;10:21-22.]

Objective: This Institutional Review Board-approved, prospective, observational study compared the clinical performance of senior medical students in an emergency medicine (EM) clerkship using a clinical behavioral evaluation tool in which one group had mandatory, topic specific readings and the other did not.

Methods: The study took place in an urban, tertiary referral center emergency department treating 43,000 patients annually and supporting medical student clerkships and an EM residency. The grades of two groups of senior medical students participating in an elective EM clerkship were compared. Those students during the 2002-2004 academic years were not assigned mandatory, topic-specific reading for the clerkship, while those during the 2004-2007 academic years were. The groups were compared on baseline demographic information, prior academic performance, and EM clerkship grade distributions using appropriate statistical techniques, including multinomial logistic regression, chi-square tests, and Fisher’s Exact tests.

Results: The control and experimental groups each had 83 subjects and were similar in baseline characteristics, except for the control group performing better than the experimental group during the basic science training of medical school (years 1-2; p=0.01). The experimental group had statistically significant more members in the EM Interest Group (EMIG; p=0.0001) and more members who went on to match in an EM residency (p=0.0007). The difference in grade distributions between the control group and experimental group was not statistically significant (p=0.40). Of note, those student members of the EMIG (p=0.0005) and those later matching to an emergency medicine residency (p<0.0001) were more likely to earn a grade of “honors” for the clerkship.

Conclusion: The addition of uniform, topic-specific reading assignments to an EM senior medical student curriculum does not improve the overall clinical performance of those students as measured using a clinical behavioral evaluation tool.

[WestJEM. 2009;10:23-29.]

Objectives: In many academic emergency departments (ED), physicians are asked to record clinical data for research that may be time consuming and distracting from patient care. We hypothesized that non-medical research assistants (RAs) could obtain historical information from patients with acute abdominal pain as accurately as physicians.

Methods: Prospective comparative study conducted in an academic ED of 29 RAs to 32 resident physicians (RPs) to assess inter-rater reliability in obtaining historical information in abdominal pain patients. Historical features were independently recorded on standardized data forms by a RA and RP blinded to each others’ answers. Discrepancies were resolved by a third person (RA) who asked the patient to state the correct answer on a third questionnaire, constituting the “criterion standard.” Inter-rater reliability was assessed using kappa statistics (κ) and percent crude agreement (CrA).

Results: Sixty-five patients were enrolled (mean age 43). Of 43 historical variables assessed, the median agreement was moderate (κ 0.59 [Interquartile range 0.37-0.69]; CrA 85.9%) and varied across data categories: initial pain location (κ 0.61 [0.59-0.73]; CrA 87.7%), current pain location (κ 0.60 [0.47-0.67]; CrA 82.8%), past medical history (κ 0.60 [0.48-0.74]; CrA 93.8%), associated symptoms (κ 0.38 [0.37-0.74]; CrA 87.7%), and aggravating/alleviating factors (κ 0.09 [-0.01-0.21]; CrA 61.5%). When there was disagreement between the RP and the RA, the RA more often agreed with the criterion standard (64% [55-71%]) than the RP (36% [29-45%]).

Conclusion: Non-medical research assistants who focus on clinical research are often more accurate than physicians, who may be distracted by patient care responsibilities, at obtaining historical information from ED patients with abdominal pain.

[WestJEM. 2009;10:30-36.]

Objectives: Premature infants are at higher risk of developing serious bacterial infections (SBI). However, the incidence of SBI in ex-premature infants presenting to the emergency department (ED) remains undetermined. The objective of this study is to examine the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks presenting to a pediatric ED.

Methods: A retrospective medical record review was conducted on 141 ex-premature infants with a postconceptional age of less than 48 weeks who had a full or partial septic work up completed in a pediatric ED between January 1, 1998 and March 31, 2005.

Results: The overall median gestational age at birth was 35 weeks (IQR 33-36 week) and the overall median postconceptional age at ED presentation was 40 weeks (IQR 37-42 weeks). Thirteen (9.2%) infants were found to have a SBI. Five subjects had pneumonia, four with bacteremia, two with pyelonephritis, and two with a concomitant infection of meningitis/pneumonia and bacteremia/pyelonephritis.

Conclusion: The results of this study reveal that the incidence of SBI in ex-premature infants with a postconceptional age of less than 48 weeks is similar to in-term infants (9.2%) and is consistent with previously published incidence rates in-term infants (10%).

[WestJEM. 2009;10:37-40.]

[WestJEM. 2009;10:41.]

Ambulance response times in Santa Barbara County for 2006 are analyzed using point process techniques, including kernel intensity estimates and K-functions. Clusters of calls result in significantly higher response times, and this effect is quantified. In particular, calls preceded by other calls within 20 km and within the previous hour are significantly more likely to result in violations. This effect appears to be especially pronounced within semi-rural neighborhoods.

[WestJEM. 2009;10:42-47.]

Background: As solid organ transplants become more common, recipients present more frequently to the emergency department (ED) for care.

Methods: We performed a retrospective medical record review of ED visits of all patients who received an organ transplant at our medical center from 2000-2004, and included all visits following the patients’ transplant surgery through December 2005 or until failed graft, lost to follow up, or death. Clinically relevant demographic variables, confounding and outcome variables were recorded. Kidney, liver and combined kidney with other organ transplant recipients were included.

Results: Five hundred ninety-three patients received kidney (395), liver (161), or combined renal (37) organ transplants during the study period, resulting in 1,251 ED visits. This represents 3.15 ED visits/patient followed over a mean of 30.8 months. Abdominal pain/gastrointestinal (GI) symptoms (31.3%) and infectious complaints (16.7%) were the most common presentations. The most common ED discharge diagnoses were fever/infection (36%), GI/Genitourinary (GU) pathology (20.4%) and dehydration (15%). Renal transplant recipients were diagnosed with infectious processes most often, despite time elapsed from transplant. Liver transplant patients had diagnoses of fever/infection most often in their first 30 days post transplant. Thereafter they were more likely to develop GI/GU pathology. After the first year of transplantation, cardiopulmonary and musculoskeletal pathology become more common in all transplant organ groups. Of the 1,251 ED visits, 762 (60.9%) resulted in hospitalization. Chief complaints of abdominal pain/GI symptoms, infectious complaints, cardiovascular and neurologic symptoms, and abnormal laboratory studies were significantly likely to result in hospitalization.

Conclusions: This study demonstrates a significant utilization of the ED by transplant recipients, presenting with a wide variety of symptoms and diagnoses, and with a high hospitalization rate. As the transplant-recipient population grows, these complex patients continue to present diagnostic and treatment challenges to primary care and emergency physicians.

[WestJEM. 2009;10:48-54.]

Autosomal dominant polycystic kidney disease may present to the emergency department (ED) with vomiting, abdominal pain or hernias, renal insufficiency or failure, or bleeding from cerebral aneurysms. A 37-year-old man presented to the ED with signs and symptoms of incarcerated inguinal hernia. Laboratory studies showed renal failure with anion gap acidosis, and bedside ultrasound showed multicystic kidneys. Computed tomography confirmed the diagnosis. Emergency physicians should be aware of this common connective tissue defect and its serious associated conditions. [WestJEM. 2009;10:55-57]

Methamphetamine (MA) use is becoming commonplace, and emergency physicians (EPs) are seeing patients with abuse-associated complications. Previous reports have described inhalational and intravenous routes. We present the second case of rectal MA abuse in the literature. Trans-rectal use is important for EPs to consider because ongoing absorption of massive quantities may be averted upon detection. Additionally, trans-rectal abuse risks anorectal trauma and vascular necrosis with colonic perforation.

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[WestJEM. 2009;10:61.]