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​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

​BY PETER GOLDMAN, MDVictims of life-threatening asthma attacks above all initially need supplemental oxygen, then nebulized or aerosolized albuterol. Dr. David Inwald, a UK pediatric intensivist, wrote in his BMJ article, "Oxygen Treatment for Acute Severe Asthma," that "the important point is that asthmatic patients are still dying during acute attacks, and the use of oxygen before, during, and after nebulised B2 agonist therapy in primary care and in the community is rational and could save lives." (2001;323[7304]:98.)That prompted an innovation to fulfill his call.During severe attacks, asthmatics are unable to negotiate an inhaler when it is used alone, and they are unable to make a seal around the spacer's mouthpiece when it is used with a spacer. Either way, albuterol inhalation is much reduced. And if the oxygen mask is already on the victim's face, it must be removed to (attempt to) provide the albuterol, depriving the victim of oxygen while tryin

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Fifteen prospective studies met inclusion criteria, with a total of 2,540 patients, for whom 8 studies obtained delayed-phase images, 11 studies obtained ECG-gated images, 9 studies achieved pulse rates lower than 70 beats/min, and only 5 studies had a combination of all 3 characteristics: ECG gating, pulse rate control, and delayed-phase imaging. Studies were reported to be of high quality (all included studies having Quality Assessment of Diagnostic Accuracy Studies score >10), and statistical heterogeneity in the delayed-phase imaging group was low.

Intravenous subdissociative-dose ketamine has been shown to be effective for pain management, but has not been specifically studied for headaches in the emergency department (ED). For this reason, we designed a study to compare standard treatment (prochlorperazine) with ketamine in patients with benign headaches in the ED.

We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma.


Investigators included 6 randomized controlled trials with 822 patients for analysis. The addition of glucagon to liquid enema versus liquid enema alone did not improve the rate of successful reduction of intussusception.1,2 Studies comparing these 2 interventions did not report on numbers of children with bowel perforations or recurrent intussusception. Air or liquid enema with dexamethasone intramuscularly versus air or liquid enema alone resulted in no benefit in regard to successful reduction or incidence of bowel perforation, although it did result in decreased risk of recurrent intussusception (risk ratio 0.14; 95% confidence interval [CI] 0.03 to 0.60), with a number needed to treat for an additional beneficial outcome (NNTB) of 13.

Eleven studies were included, with a total of 9,241 patients. Overall acute myocardial infarction prevalence was 15.4%. Of the total included patient population, 30.6% were classified as being at low risk for acute myocardial infarction by a single negative hs-cTnT result and a nonischemic ECG result. Of these patients, 14 (0.5%) received a diagnosis of acute myocardial infarction. In 7 of these cases, the time between symptom onset and blood sampling was less than 3 hours. The pooled performance estimates for the primary and secondary outcomes of acute myocardial infarction and major adverse cardiac events are presented in the Table.

In recent years, the use of novel anticoagulants and antiplatelet agents has become widespread. Little is known about the toxicity and bleeding risk of these agents after acute overdose. The primary objective of this study is to evaluate the relative risk of all bleeding and major bleeding in patients with acute overdose of novel antiplatelet and anticoagulant medications.

We examine the availability of follow-up appointments for emergency department (ED) patients without established primary care by insurance and clinical condition.

To describe the current epidemiology of bacteremia in febrile infants 60 days of age and younger in the Pediatric Emergency Care Applied Research Network (PECARN).

Two large randomized trials recently demonstrated efficacy of methicillin-resistant Staphylococcus aureus (MRSA)–active antibiotics for drained skin abscesses. We determine whether outcome advantages observed in one trial exist across lesion sizes and among subgroups with and without guideline-recommended antibiotic indications.

The study aims to identify modifiable factors associated with improved out-of-hospital cardiac arrest survival among communities in the Pan-Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network: Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and the United Arab Emirates (Dubai).

Vascular access is an essential procedure in the emergency department (ED). In patients with difficult intravenous access, alternatives to the traditional blind cannulation should be considered, including cannulation of an external jugular vein, a peripheral vein in the upper or lower extremity with real-time ultrasonographic guidance, or a central vein with ultrasonographic guidance.1,2 Intraosseous lines and venous cutdowns may also be considered for unstable patients.3 However, even with ultrasonographic guidance, peripheral venous cannulation may be unsuccessful and central venous cannulation is both time consuming and associated with potential complications, including infection, thrombosis, pneumothorax, and arterial injury.

We study adverse health effects after use of the new psychoactive substance 4-fluoroamphetamine.

Little is known about the use of ibutilide for cardioversion in atrial fibrillation and flutter outside of clinical trials. We seek to describe patient characteristics, ibutilide administration patterns, cardioversion rates, and adverse outcomes in the community emergency department (ED) setting. We also evaluate potential predictors of cardioversion success.

Analyses of 72-hour emergency department (ED) return visits are frequently used for quality assurance purposes and have been proposed as a means of measuring provider performance. These analyses have traditionally examined only patients returning to the same hospital as the initial visit. We use a health information exchange network to describe differences between ED visits resulting in 72-hour revisits to the same hospital and those resulting in revisits to a different site.

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