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

Objective: The accuracy of pre-hospital crash scene details and crash victim assessment has important implications for initial trauma care assessment and management. Similarly, it is known to influence physician perception of crash victim injury severity. The goal of this feasibility study was to examine paramedic accuracy in predicting crash victim injury profile, disability outcome at hospital discharge, and reporting vehicle damage with other crash variables.

Methods: This prospective case series study was undertaken at a Southern California, Level I trauma center certified by the American College of Surgeons. Paramedics transporting crash injured motor vehicle occupants to our emergency department (ED)/trauma center were surveyed. We abstracted ED and in-patient records of injured vehicle occupants. Vehicle and crash scene data were obtained from a professional crash reconstruction, which included the assessment of deformation, crash forces, change in velocity, and the source of each injury.

Results: We used survey, injury, and crash reconstruction data from 22 collision cases in the final analysis. The median Injury Severity Score (ISS) was five (range 1-24). No enrolled patients died, and none were severely disabled at the time of discharge from the hospital. The paramedic crash injury severity predictions were sensitive for an Abbreviated Injury Scale (AIS) of 2-4. Paramedics often agreed with the crash reconstruction on restraint use, ejection, and other fatalities at the scene, and had lower levels of agreement for front airbag deployment, steering wheel damage, and window/windshield impact. Paramedics had 80% accuracy in predicting any disability at the time of hospital discharge.

Conclusion: Paramedic prediction of injury profile was sensitive, and prediction of disability outcome at discharge was accurate when compared to discharge diagnosis. Their reporting of vehicle specific crash variables was less accurate. Further study should be undertaken to assess the benefits of crash biomechanics education for paramedics and other pre-hospital care providers. [WestJEM. 2009;10:62-67.]

Introduction: Sudden, unexpected arrest-related death (ARD) has been associated with drug abuse, extreme delirium or certain police practices. There is insufficient surveillance and causation data available. We report 12 months of surveillance data using a novel data collection methodology.

Methods: We used an open-source, prospective method to collect 12 consecutive months of data, including demographics, behavior, illicit substance use, control methods used, and time of collapse after law enforcement contact. Descriptive analysis and chi-square testing were applied.

Results: There were 162 ARD events reported that met inclusion criteria. The majority were male with mean age 36 years, and involved bizarre, agitated behavior and reports of drug abuse just prior to death. Law enforcement control techniques included none (14%); empty-hand techniques (69%); intermediate weapons such as TASER device, impact weapon or chemical irritant spray (52%); and deadly force (12%). Time from contact to subject collapse included instantaneous (13%), within the first hour (53%) and 1-48 hours (35%). Significant collapse time associations occurred with the use of certain intermediate weapons.

Conclusion: This surveillance report can be a foundation for discussing ARD. These data support the premise that ARDs primarily occur in persons with a certain demographic and behavior profile that includes middle-aged males exhibiting agitated, bizarre behavior generally following illicit drug abuse. Collapse time associations were demonstrated with the use of TASER devices and impact weapons. We recommend further study in this area to validate our data collection method and findings. [WestJEM. 2009;10:68-73.]

Spinal immobilization is one of the most commonly performed pre-hospital procedures. Little research has been done on the movement of the neck during immobilization and extrication. In this study we used a sophisticated infrared six-camera motion-capture system (Motion Analysis Corporation, Santa Rosa, CA), to study the motion of the neck and head during extrication. A mock automobile was constructed to scale, and volunteer patients, with infrared markers on bony prominences, were extricated by experienced paramedics. We found in this pilot study that allowing an individual to exit the car under his own volition with cervical collar in place may result in the least amount of motion of the cervical spine. Further research should be conducted to verify these findings. In addition, this system could be utilized to study a variety of methods of extrication from automobile accidents. [WestJEM. 2009;10:74-78.]

Objective: To determine the prevalence of adverse events in elderly trauma patients with isolated blunt thoracic trauma, and to identify variables associated with these adverse events.

Methods: We performed a chart review of 160 trauma patients age 65 and older with significant blunt thoracic trauma, drawn from an American College of Surgeons Level I Trauma Center registry. Patients with serious injury to other body areas were excluded to prevent confounding the cause of adverse events. Adverse events were defined as acute respiratory distress syndrome or pneumonia, unanticipated intubation, transfer to the intensive care unit for hypoxemia, or death. Data collected included history, physical examination, radiographic findings, length of hospital stay, and clinical outcomes.

Results: Ninety-nine patients had isolated chest injury, while 61 others had other organ systems injured and were excluded. Sixteen patients developed adverse events [16.2% 95% confidence interval (CI) 9.5-24.9%], including two deaths. Adverse events were experienced by 19.2%, 6.1%, and 28.6% of those patients 65-74, 75-84, and >85 years old, respectively. The mean length of stay was 14.6 days in patients with an adverse event and 5.8 days in patients without. Post hoc analysis revealed that all 16 patients with an adverse event had one or more of the following: age ≥85, initial systolic blood pressure <90 mmHg, hemothorax, pneumothorax, three or more unilateral rib fractures, or pulmonary contusion (sensitivity 100%, CI 79.4-100%; specificity 38.6%, CI 28.1-49.9%).

Conclusion: Adverse events from isolated thoracic trauma in elderly patients complicate 16% of our sample. These criteria were 100% sensitive and 38.5% specific for these adverse events. This study is a first step to identifying variables that might aid in identifying patients at high risk for serious adverse events. [WestJEM. 2009;10:79-84.]

Objective: To determine the point prevalence of urine bilirubin, urine hemoglobin and urobilinogen in blunt trauma patients, and to evaluate its utility as a screening tool for intra-abdominal injury.

Methods: Data analysis of 986 consecutive trauma patients of which 698 were adult blunt trauma patients. Five-hundred sixteen subjects had a urinalysis and a CT scan of the abdomen/pelvis or exploratory laparotomy. We reviewed initial urinalysis results from trauma patients in the emergency department (ED) for the presence of urine hemoglobin, uroblinogen and urine bilirubin. Computed tomography (CT) scan results and operative reports were reviewed from the trauma registry for evidence of liver laceration, spleen laceration, bowel or mesenteric injuries.

Results: There were 73 injuries and 57/516 patients (11%) with intra-abdominal injury. Urinalysis was positive for urobilinogen in 28/516 (5.4%) patients, urine bilirubin in 15/516 (2.9%) patients and urine hemoglobin in 313/516 (61%) patients. Nineteen/forty-seven (4%) subjects had liver lacerations, 28/56 (5%) splenic lacerations, and 15/5 (3%) bowel or mesenteric injury. Comparing the proportion of patients that had urobilinogen detected in the group with and without intra-abdominal injury, 8/28 (29%) subjects with urobilinogen, 5/15 (33%) subjects with bilirubin and 47/313 (15%) subjects with urine hemoglobin were found to have liver lacerations, spleen lacerations, or bowel/mesenteric injuries. Preexisting liver or biliary conditions were not statistically associated with elevation of urine bilirubin, urine hemoglobin or urobilinogen on initial urinalysis after blunt abdominal trauma. Point prevalence for urobilinogen, urine bilirubin and urine hemoglobin are 5.43% (28/516), 2.91% (15/516) and 60.7% (313/516) respectively.

Conclusions: The utility of the initial routine urinalysis in the ED for adult blunt abdominal trauma patients should not be used as a screening tool for the evaluation of intra-abdominal injury. [WestJEM. 2009;10:85-88.]

A 42-year-old male presented to the emergency department with pain and swelling of his distal right wrist. Bedside ultrasound placed over the swelling revealed a pseudoaneurysm of the radial artery. The patient received percutaneous thrombin injection of the aneurysm sac followed by direct ultrasound compression therapy of the pseudoaneurysm neck, resulting in thrombosis of the sac. The use of bedside ultrasound by the emergency physician led to appropriate care and proper disposition for definitive management. [WestJEM. 2009;10:89-91.]

[WestJEM. 2009;10:92.]

Objective: Determine the effect that increased medical surgical (med/surg) bed occupancy has on the time interval from admission order to arrival in the bed for the patients admitted from the emergency department (ED).

Methods: This retrospective observational study compares the total hospital bed occupancy rate and the medical surgical inpatient bed occupancy rate to daily averages for the time interval from admission order (patient posting for admission) to the patient’s arrival in the inpatient bed. Medical surgical inpatient bed occupancy of 92% was chosen because beyond that rate we observed more frequent extended daily transfer times. The data is from a single large tertiary care institute with 590 beds and an annual ED census of 80,000.

Results: Group 1 includes 38 days with (med/surg) inpatient bed occupancy rate of less than 92%, with an average ED daily wait of 2.5 hrs (95% confidence interval 2.23-2.96) for transfer from the ED to the appropriate hospital bed. Group 2 includes 68 days with med/surg census greater than 92% with an average ED daily wait of 4.1 hours (95% confidence interval 3.7-4.5). Minimum daily average for the two groups was 1.2 hrs and 1.3 hrs, respectively. The maximum average was 5.6 hrs for group 1 and 8.6 hrs for group 2. Comparison of group 1 to 2 for wait time to hospital bed yielded p <0.01. Total reported hospital occupied capacity shows a correlation coefficient of 0.16 to transfer time interval, which indicates a weak relationship between total occupancy and transfer time into the hospital. Med/surg occupancy, the beds typically used by ED patients, has a 0.62 correlation coefficient for a moderately strong relationship.

Conclusions: Med/surg bed occupancy has a better correlation to extended transfer times, and occupancy over 92% at 5 AM in our institution corresponds to an increased frequency of extended transfer times from the ED. The process of ED evaluation, hospital admission, and subsequent transfer into the hospital are all complex processes. This study begins to demonstrate one variable, med/surg occupancy, as one of the intervals that can be followed to evaluate the process of ED admission and hospital flow. [WestJEM. 2009;10:93-96.]

Objectives: This is a prospective study of psychiatric patients presenting to the emergency department (ED) to determine the value of routine laboratory studies used to attempt to exclude concomitant medical illness.

Methods: Physical exams and laboratory tests were performed on 375 psychiatric patients presenting for “medical clearance” in the ED. Upon completion of these tests, the percentage and impact of abnormal physical exams and laboratory results were assessed.

Results: Fifty-six of 375 patients (14.9%) had a non-substance-induced laboratory abnormality. Forty-two of these 56 patients (75.0%) also had abnormal history or physical exam findings indicating laboratory screening. Ten had normal history and physical exams with insignificant laboratory abnormalities. The four (1.1% [95% CI 0.3-2.7%]) remaining patients with normal history and physical exams had abnormal urinalyses which did not affect final disposition or contribute to altered behavior.

Conclusion: Patients presenting to the ED with psychiatric chief complaints, benign histories and normal physical exams have a low likelihood of clinically significant laboratory findings. [WestJEM. 2009;10:97-100.]

Objectives: To study whether emergency department (ED) visits by male patients wane simultaneously with the play of scheduled professional and college sports events.

Methods: Retrospective cohort analysis looked at ED male patient registration rates during a time block lasting from two hours before, during, and two hours after the play of professional football games (Monday night, Sundays, post-season play), major league baseball, and a Division I college football and basketball team, respectively. These registration rates were compared to rates at similar times on similar days of the week during the year devoid of a major sporting contest. Games were assumed to have a play time of three hours. Data was collected from April 2000 through March 2003 at an urban academic ED seeing 33,000 male patients above the age of 18 years annually.

Results: A total of 782 games were identified and used for purposes of the study. Professional football game dates had a mean of 17.9 males (95% confidence interval [CI] 17.4-18.4) registering vs. 26.8 males (95% CI 25.9-27.6) on non-game days. A registration rate for major league baseball was 18.4 patients (95% CI 17.6-18.4). The mean for registration on comparable non-game days was 23.9 patients (95% CI 22.8-24.3). For the regional Division I college football team, the mean number of patients registering on game days and non-game days was 21.7 (95% CI 20.9-22.4) and 23.4 (95% CI 22.9-23.7), respectively. Division I college basketball play for game and non-game days had mean rates of registration of 14.5 (95% CI 13.9-15.1) and 15.5 (95% CI 15.1-15.9) patients, respectively. For all sports dates collectively, a comparison of two means yielded a mean of 18.2 patients (95% CI 17.4-18.8) registering during the study hours on game days vs. 23.3 patients (95% CI 22.0-23.7) on non-game days. The mean difference was 5.1 patients (95% CI 3.7 to 7.0) with p < .000074.

Conclusion: Male patient visits to the ED decline during major sporting events. [WestJEM. 2009;10:101-103.]

Introduction: The purpose of this paper was to review and analyze all the literature concerning ED patient throughput. The secondary goal was to determine if certain factors would significantly alter patients’ ED throughput.

Methods: A MEDLINE search was performed from 1966 to 2007 using the terms “turnaround,” “emergency departments,” “emergency medicine,” “efficiency,” “throughput,” “overcrowding” and “crowding.” Studies were graded using a scale of one to four based on the ACEP paper quality criteria. Inclusion criteria were English language and at least a level four or better on the quality scale. An analysis of successful procedures and techniques was performed.

Results: Literature search using the key terms found 29 articles on turnaround times, 129 on ED efficiency, 3 on throughput, 64 on overcrowding and 52 on crowding. Twenty-six articles were found to meet the inclusion criteria. There were three level I studies, thirteen level II studies, five level III studies and five level IV studies. The studies were categorized into five areas: determinants (7), laboratories processes (4), triage process (3), academic responsibilities (2), and techniques (10). Few papers used the same techniques or process to examine or reduce patient throughput precluding a meta-analysis.

Conclusions: An analysis of the literature was difficult because of varying study methodologies and less than ideal quality. EDs with combinations of low inpatient census, in-room registration, point of care testing and an urgent care area demonstrated increased patient throughput. [WestJEM. 2009;10:104-109.]

While the supraclavicular approach to the subclavian vein has been described since 1965, it is generally employed much less often than the “traditional” infraclavicular approach. Although randomized trials are lacking, the best evidence suggests that the supraclavicular approach has a number of important advantages to the infraclavicular approach. The landmarks and relative merits of the procedure are described in this paper. [WestJEM. 2009;10:110-114.]

This case report describes a 54-year-old male on warfarin for atrial fibrillation who presented to the emergency department (ED) following a syncopal episode with persistent hypotension. The patient’s International Normalized Ratio (INR) returned elevated at 6.0, and a rapid bedside cardiac ultrasound revealed a large pericardial effusion consistent with cardiac tamponade. The anticoagulation was reversed and the patient underwent successful pericardiocentesis with removal of 1,100 mL of blood. [WestJEM. 2009;10:115-119.]

Academic writing is a critical skill distinct from creative writing. While brevity is vital, clarity in writing reflects clarity of thought. This paper is a primer for novice academic writers. [WestJEM. 2009;10:120-123.]

Some researchers and consulting groups have promoted managed care as a way to provide cost-effective quality care to Medicaid patients, based on assertions that are often poorly substantiated. Unfortunately, politicians and policy makers in California and other states have adopted the presumption of the cost-effectiveness of Medicaid Managed Care as a rationale for expanding the use of managed care programs to include a larger share of more Medicaid eligible enrollees, and expand coverage and services to the currently uninsured. This paper challenges the assertion that Medi-Cal Managed Care is cost effective, by demonstrating that the unique and idiosyncratic manner in which Medi-Cal managed care has been implemented in California (and other states) creates perverse incentives leading to cost-shifting and selective enrollment and dis-enrollment of costly beneficiaries. This places an unfair burden on fee-for-service Medi-Cal providers, who are expected to provide more services for less reimbursement. Administrators of Medicaid Managed Care programs need to consider risk adjusted rates for beneficiaries enrolled in plans in order to align incentives with program objectives. [WestJEM. 2009;10:124-129.]

Acute hemorrhagic conjunctivitis is an uncommon cause of eye redness and pain in non-tropical regions. We present a case of a patient who presented to a United States emergency department with this ocular pathology and discuss the presentation, diagnosis and treatment. [WestJEM. 2009;10:e9.]