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​BY JONATHAN D. MILLER, MDThe seat belt sign chimes again. Pinned between two strangers for hours, I silently wish for a brief reprieve—beverage service or a chance to hobble toward the back of the plane to stretch. But, no, the captain has turned on the seat belt sign again. She's the boss, and I trust her with my safety, regardless of how uncomfortable I might be.Many analogies have been drawn between the seemingly different worlds of aviation and medicine over the years. Many have continued to look for similarities since Dr. Atul Gawande wrote The Checklist Manifesto. One of the best lectures I've heard was from fellow emergency physician Dr. Joe Novak who spoke at the ACEP Scientific Assembly about combat aviation paradigms" comparing our craft and our training to that of an Air Force fighter pilot. As a pilot and emergency physician, I think there are more comparisons yet to be made.The aviation industry is plagued with bureaucracy. It makes sense to the lay passeng

​BY FRANK DEL VECCHIO, MD​When I first heard of the shooting in Las Vegas a few days ago, it sounded as if only a few people were injured. I was preparing for bed, but as soon as I realized the scope of the incident, I went immediately to the emergency department. I ran several red lights as ambulances do, exceeded speed limits by a factor of 2+, and was quickly waved through police barricades when I showed my hospital ID.I would like to say that I heroically saved dozens of lives by performing numerous invasive bloody procedures, but that was not the case. Most of the serious cases were already handled when I got there. We had one DOA, and all the others are expected to survive, but many will have permanent injuries.When I arrived, I was immediately struck by how quiet it was. Nothing moved me more than how patients with horrific injuries heroically suffered in silence while the staff worked diligently to care for all. They knew we would get to them as soon as possible and in order of

BY STEPHEN HAIRE, MD​Rapidly treating sepsis patients with antibiotics is absolutely vital to their survival. Even an hour or two of delay could cost a patient his life. But as U.S. hospitals are striving to implement effective sepsis protocols, many feel torn between that and a parallel and equally important national effort—our need to reduce antibiotic overuse and misuse, which is a primary driver of our growing antibiotic resistance problem. Ironically, we at Morton Plant Hospital BayCare Health System (MPMHC) learned that these two goals don't have to be at cross-purposes. The key to optimizing these essential goals is the biomarker procalcitonin or PCT.No one has ever said to me in my 20 years as an emergency physician, "Doctor, I think I may have sepsis." In fact, more than 40 percent of those surveyed said they had never heard of the term "sepsis," according to a 2015 survey by the Sepsis Alliance. (http://bit.ly/2xaoL5v.) Have we done a poor job explain

​BY MARTHA ROBERTS, ACNP, PNP​News stories flooding social media, the internet, and television sparked outrage after a police officer's body camera video showed the arrest of a Salt Lake City, UT, nurse, Alex Wubbels, in July. Ms. Wubbels, who said she was protecting the rights of her unconscious patient, was arrested for obstruction of justice for refusing to provide the police with blood samples without a warrant, the patient's consent, or a stated intent to arrest the patient. Recordings of the scene showed Ms. Wubbels being dragged out of the hospital by a police officer. (NBC News. Sept. 4, 2017; http://nbcnews.to/2xbHZYM.)This story generated questions about police brutality against patients and health care workers involved in their care, as well as about the communication between medical providers and the police. Patients and health care workers are at risk of police maltreatment, and it is a growing threat and issue.Police brutality and medical negligence are concerns

​BY PAUL MARIK, MBBChBelow is a list of the most common questions that have been asked in response to our paper, "Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study" (Chest 2016), and our best answers.Q1. Why was the mortality rate in your control group so high relative to world averages?A. When we began using this "cocktail," we were unsure of its benefits (and risks), and we therefore only used the cocktail in patients at highest risk of dying and developing progressive organ failure. To receive the cocktail, patients must be admitted via our emergency department with severe sepsis or septic shock and an initial procalcitonin (PCT) >2. (We routinely measure PCT in all our patients suspected of having sepsis.)The median procalcitonin in the treatment and control groups were 25 ng/ml and 15 ng/ml respectively. The median PCT in the MOSES study, the largest study to date to evaluate the t

BY SETH COLLINGS HAWKINS, MD; JUSTIN SEMPSROTT, MD; & ANDREW SCHMIDT, DO, MPHEarlier this month a young child died following days of vomiting. He had been in shallow water in a Texas dike about a week before his death. The story was picked up as an alleged case of a rare condition called dry drowning or secondary drowning. (CNN. June 9, 2017; http://cnn.it/2rECrOV.) The media accounts went viral, spreading significant fear in parenting communities and among those learning about these alleged conditions from the news or social media.Every death is tragic, especially when it is a child's. Our heartfelt sympathies go out to the family and to those who treated the patient. Drowning deaths are a common cause of pediatric death, and we need to be particularly vigilant about sharing correct, meaningful, and medically credible information.Unfortunately, there is significant misinformation in the media reports of this case, and we hope this evidence-based discussion of drowning and the

​BY JACKIE LAMThe American College of Emergency Physicians' public censure of Peter Rosen, MD, shed light on how expert witness testimonies are especially problematic for EPs. Emergency Medicine News spoke with David Sklar, MD, a distinguished professor emeritus of emergency medicine at the University of New Mexico and an author of the paper, The Expert Witness in Emergency Medicine, about the reasons behind that and the need for an alternative system to address medical errors. (Ann Emerg Med 2014;63[6]:731.)Unlike other medical specialties, emergency physicians often have to treat based on incomplete information, with patients they don't know, and whose conditions are not always clear. "In many cases, what you're dealing with are probabilities. For example, someone has chest pain," Dr. Sklar said. "They may have a five percent probability of a heart attack, so now you have to make a decision. Is five percent a high enough number that I need to admit this

Eight major emergency medicine organizations have formed the Coalition to Oppose Medical Merit Badges, pledging to eliminate hospital requirements that board-certified emergency physicians obtain certification in advanced resuscitation, trauma care, stroke care, cardiovascular care, or pediatric care needed for medical staff privileges.The organizations also said mandatory continuing medical education requirements "do not offer any meaningful value for the public or for the emergency physician who has achieved and maintained board certification," saying those conditions are often promulgated by others who "incompletely understand the foundation of knowledge and skills" acquired by successfully completing an emergency medicine residency program approved by the Accreditation Council for Graduate Medical Education.These merit badges, the news release stated, add no additional value for board-certified emergency physicians and devalue the board certification process by

UPDATE, March 29, 2017: SummaHealth lost its ACGME appeal, and its emergency medicine residency will close July 1. The emergency medicine residency program at Summa Health in Ohio lost its accreditation and was placed on probation by the Accreditation Council on Graduate Medical Education, according to the Akron Beacon Journal. (http://bit.ly/2ku7ryw.)ACGME said it will withdraw the accreditation on July 1, though Summa said it would appeal the decision within the 30 days ACGME allotted for that process.Other emergency medicine residency programs in Ohio have offered to help Summa's first- and second-year residents find new slots to finish their training, but nothing official has been announced.The SUMMA emergency medicine residency program was started in 1980 by Summa Emergency Associates (SEA), the physician group that staffed Summa's five emergency departments for 40 years but that lost its contract on Jan. 1 to US Acute Care Solutions.​Read the EMN article about that belo

BY RUTH SORELLE, MPHThe lightning-swift switch in emergency department physician staffing at Summa Health System in Akron, OH, turned out to be the final straw for the hospital's board of directors. What started with the emergency physician group being replaced on Jan. 1 ended only 25 days later with the Summa board of directors accepting the resignation of Thomas Malone, MD, the controversial president and CEO whose actions sparked the turmoil.Those involved in the dispute between the Summa Health System and the emergency medicine group, Summa Emergency Associates (SEA) that staffed its emergency departments for 40 years, agreed on one thing: At midnight on New Year's Eve, the system's contract with SEA ended and one hastily written and approved with US Acute Care Solutions (USACS) was activated."The night of the transition, they [physicians from USACS] came in an hour early," said Jeffrey Wright, MD, the president of SEA. "We had all the patients taken c

This article will appear in the February issue of EMN.​BY RUTH SORELLE, MPH A New York emergency physician who has lectured and written extensively on evidence-based medicine and the doctor-patient relationship admitted in a New York court on Dec. 16 to five counts of sexually assaulting four female patients in the emergency department at Mount Sinai Hospital.A source close to the proceedings said on background that 45-year-old David Newman, MD, pled guilty to all counts of the indictment against him, and was promised by Judge Michael Obus of the Supreme Court a sentence of two years in prison and three years of post-release supervision. Prosecutors had sought four years in prison with 10 years of post-release supervision. Dr. Newman was scheduled for sentencing on Jan. 23, and remained free on $50,000 bond at press time. Neither he nor his attorney returned calls from Emergency Medicine News about the case.Dr. Newman was suspended immediately after the allegations came to light, said

(Last verse only; you're welcome.) BY SCOTT GOLDSTEIN, DOOn the twelfth day of Christmas, the ER sent to me:12 drunks drinking,Eleven addicts withdrawing,Ten ankles-a-limping,Nine bellies aching,Eight backs-a-hurting,Seven trichs-a-swimmingSix geezers-a-laying,Five kidney stones.Four calling codes,Three head bleeds,Two aortas rupturing,and a VIP in bed 3.​Dr. Goldstein is a clinical associate professor of emergency medicine, the director of EMS/disaster medicine, and the director of tactical medicine at Einstein Healthcare Network in Philadelphia. Read his blog, Visual Diagnosis in the ED, at http://visdxed.blogspot.com/, and follow him on Twitter @erdocsg.​Tags: Christmas, parodyPublished: 12/14/2016 2:00:00 PM

​(Sing to the tune of Adam Sandler's "Chanukah Song.")BY SCOTT GOLDSTEIN, DO​Put on your PPE,It's time for TraumakahSo much funukahTo be covered in bloodikah. Traumakah is the festival of fights.Instead of one day of violence, we have eight crazy nights. When you feel like the only doc in town without a specialty phone tree,Here are some things we ED docs deal with every day,just like you and me. New trauma attendings use REBOA,So do their residents.Vascular surgeons on the late gunshots that come through the doorah.Guess who does compressions near the belly.First-year interns and ED techs when ready. Staples closehalf the woundish,Steri-Strips the otherhalf, too.Put them together, what a fine lookin' crew! You don't need "Deck the Halls" or "Jingle Bell Rock"'Cause you canaccess the IJ with USor a finder needle;both acceptable. Put on your PPE,It's time for Traumakah! The owner ofyour hospital probablycelebrates Chanukah.Hemo

Dr. Walker interviews Alexis LaPietra, DO, about her Alternatives to Opiates (ALTO) program in his December 2016 and January 2017 columns, where these protocols appear. They are published here to include the references that went into creating them.ALTO Clinical ApplicationsRenal Colic1. Toradol 30 mg IV2. Cardiac lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)    a. Patient should be on a cardiac monitor.3. Acetaminophen 975 mg PO4. 1 L NS bolusMusculoskeletal Pain (sprains, strains, or opiate naïve lower back pain)1. Acetaminophen 975 mg PO2. Motrin 600 mg PO or Toradol 30 mg IV/IM3. Muscle relaxant (choose one of the following)    a. Flexeril 5 mg PO (patients >65 years old or 70 kg)    c. Valium 5 mg PO4. Lidoderm patch to most painful area, MAX 3 patches. Instruct patient to remove after 12 hours.5. Gabapentin (neuropathic component of pain)    a. 300 mg PO (patients >65 years old or 70 kg or not naïve to med)6. Trigger point injection with 1-2 mL of Marcaine

​Published: 8/10/2016 2:46:00 PM

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This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman’s Access high-sensitivity troponin I assay.

We assess whether an automated prescription drug monitoring program intervention in emergency department (ED) settings is associated with reductions in opioid prescribing and quantities.

Outpatient management of emergency department (ED) patients with acute pulmonary embolism is uncommon. We seek to evaluate the facility-level variation of outpatient pulmonary embolism management and to describe patient characteristics and outcomes associated with home discharge.

Emergency physicians are often the first physician contact for women with bleeding from first-trimester miscarriage, which is the most common gynecologic emergency; 1 in 4 women experiences miscarriage in her lifetime.1,2 Up to 31% of pregnancies end in miscarriage, contributing to the 1.6% (500,000) of emergency department (ED) visits in the United States annually that are prompted by vaginal bleeding in pregnancy.3-7 Despite the emergency physician’s role as a specialist in hemodynamic stabilization, scant emergency medicine literature addresses the management of patients with hemodynamically significant uterine bleeding in the ED.

Authors included 115 randomized controlled trials (60,479 women) from 2,511 studies screened, 92 of which were conducted in China. Study inclusion and exclusion criteria were similar among included trials, with exclusion of women evaluated after 72 hours and those with multiple episodes of unprotected intercourse, with irregular menstrual periods, or using hormonal contraception. Double blinding occurred in 23 trials.

The search identified 1,396 articles, of which 44 were deemed eligible for full-text review. Of these, a total of 8 articles (n=609 patients) were included in the final qualitative analysis. The review included 6 randomized controlled trials and 2 observational studies. Five studies were conducted in the United States, with the remainder conducted in France, India, and Iran. Most of the randomized controlled trials used low-dose ketamine, with doses ranging from 0.1 to 0.5 mg/kg given intravenously; however, one study followed the initial intravenous dose with a subcutaneous infusion at 0.1 mg/kg per hour.

The authors included 25 randomized controlled trials with a total of 3,278 adult and pediatric patients. They found that various topical cocaine-free agents provided adequate analgesia; however, comparison of specific agents was not possible because of high risk of bias among comparison studies. In 2 pooled studies, self-reported improvement in visual analog scale scores (0 to 100 mm), the improvement was greater for topical prilocaine-phenylephrine compared with topical tetracaine-epinephrine-cocaine, with a difference of 5.6 points.

The search strategy identified 648 articles, of which 10 trials (6,285 total participants) met the inclusion criteria. The studies were published between 2007 and 2016, and none were determined to be at high risk of bias. Six studies were performed in the ED and 4 studies were performed in the inpatient setting. The mean age ranged from 50 to 60 years, and the percentage of female patients ranged from 42% to 63%. Eight studies excluded patients with known coronary artery disease. Standard of care included myocardial perfusion imaging in 8 studies, stress ECG in 5 studies, and stress echocardiogram in 2 studies.

During the past 40 years, significant progress has been made with integrating the practice of emergency medicine and critical care medicine. Since 1976, a small number of US emergency physicians have pursued training in critical care medicine.1 Growth has been steady and relatively slow, mostly because of a lack of fellowship opportunities and board certification. In 2005, the neurocritical care board certification pathway was opened to emergency physicians2; in 2013, the American Board of Emergency Medicine negotiated a board certification pathway through agreements with internal medicine, surgery, and anesthesia.

Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim is to quantify the frequency of short-term adverse outcomes of children with isolated skull fractures.

Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits.

Three percent of emergency department (ED) patients present with dizziness, vertigo, lightheadedness, or imbalance.1 These words are not diagnostically meaningful.2 Rather, it is the timing and the factors that trigger the dizziness that best inform the differential diagnosis.3 Asking a patient, “What do you mean by ‘dizzy’?” is less important than defining the rapidity of onset, the context, presence of associated symptoms, the intermittent or persistent nature of the dizziness, and triggers of intermittent symptoms.

Several systematic reviews have previously shown that the risk of bleeding with long-term treatment with aspirin was lower than with warfarin.2,3 It is common clinical practice to use antiplatelet agents as alternatives to anticoagulation in patients with atrial fibrillation and low risk of stroke or for those with contraindications to anticoagulants. However, the latest guidelines no longer recommend the use of aspirin for atrial fibrillation regardless of age.4 Although it is well known that age increases the risk of bleeding, this systematic review aimed to evaluate whether bleeding risk is equivalent among all antithrombotic drugs.

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