Train for the Game: What Is the Learning Environment of Deployed Navy Emergency Medicine Physicians?

OBJECTIVES: Medicine is a practice characterized by ongoing learning, and unique qualities of the operational learning environment (LE) may affect learner needs. When physicians move between differing practice environments learners may encounter situations for which they are unprepared. Using a conceptual framework specific to the LE, we therefore asked the following research question: what is the difference in LE for Navy emergency medicine (EM) physicians who practice in U.S. hospitals but serve an operational environment, and how do these differences shape their learning needs? METHODS: We interviewed Navy EM physicians who recently deployed to explore their perceptions of the deployed LE, how it differed from the LE they practice in stateside, and the perceived effect this difference had on their learning needs. We used the constant comparative method to gather and analyze data until thematic saturation was achieved. RESULTS: We interviewed 12 physicians and identified six interconnected themes consistent with the LE framework in the literature: 1) patient care is central to the learning experience; 2) professional isolation versus connectedness; 3) a sense of meaningful practice engages the learner in the LE; 4) physicians as educators shape the LE; 5) team trust impacts the LE; and 6) the larger military organization impacts the LE. CONCLUSIONS: Our themes span the conceptual framework put forth by previous work and did not find themes outside this framework. These interconnected themes describe the difference in LE between the stateside and deployed setting and impact the learning needs of Navy EM physicians. These results inform strategies to position the deployed medical unit for success.

Bilateral tibial tubercle avulsion fractures: A pediatric orthopedic injury at high risk for compartment syndrome.

Adolescent tibial tubercle avulsion fractures represent an uncommon, but clinically significant condition for emergency medicine physicians. Early recognition of the signs and symptoms of this pediatric orthopedic diagnosis are important, as anterior compartment syndrome can occur in up to 10-20% of cases. Anterior tibial tubercle fractures are generally sport related injuries, occurring primarily in otherwise healthy adolescent males between the ages of 11-17. They account for less than 3% of all epiphyseal injuries in this age group and are rarely bilateral in nature. In this article, we present a case with two unique clinical features: bilateral sports related tibial tubercle avulsion fractures and subsequent development of bilateral clinical compartment syndrome. We briefly review the risk factors, presentation, and diagnosis of this rare but clinically important condition.

Comparison of pediatric post-reduction fluoroscopic- and ultrasound forearm fracture images.

OBJECTIVE: Emergency department (ED) reduction of pediatric fractures occurs most commonly in the forearm and can be challenging if fluoroscopy is not available. We sought to assess the ability of point of-care ultrasonography (POCUS) to predict adequacy of reduction by fluoroscopy. METHODS: We prospectively enrolled ED patients 0-17 years of age with radial and/or ulnar fractures requiring reduction under fluoroscopic guidance. Post-reduction POCUS (probe dorsal, volar, and coronal) and fluoroscopic (AP and lateral) fracture images were recorded. Fracture angles were compared between blinded POCUS and fluoroscopic measurements and between POCUS measurements by a blinded emergency physician and a blinded radiologist, reporting mean differences and 95% confidence intervals. We calculated sensitivity, specificity, and likelihood ratios of POCUS in the prediction of fluoroscopically detected post-reduction malalignment, as interpreted by a blinded pediatric orthopaedist. RESULTS: The 58 patients were 7.9 ±â€¯3.5 years of age and had 21 radial (36%), 1 ulnar (2%), and 36 radioulnar (62%) fractures. Fluoroscopy and POCUS angles were within a mean of 0.1°-3.2°, depending on the site and surface measured. Radiologist- and emergency physician-interpreted POCUS measurements were within a mean of 1° in all dimensions. POCUS identified inadequate reductions with 100% sensitivity and 92-93% specificity. CONCLUSIONS: Blinded emergency medicine and radiology interpretations of post-reduction POCUS fracture images agree closely. Post-reduction POCUS measurements are comparable to those obtained by fluoroscopy and accurately predict adequacy of reduction. POCUS can be used to guide pediatric fracture reduction when bedside fluoroscopy is not available in the ED.

Equipping Public Spaces to Facilitate Rapid Point-of-Injury Hemorrhage Control After Mass Casualty.

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

Post-Mortem Evaluation of Potentially Survivable Hemorrhagic Death in a Civilian Population.

BACKGROUND: Although the survivability of military extremity hemorrhage is well documented, equivalent civilian data are limited. We analyzed statewide autopsy records in Maryland to determine the number of hemorrhagic deaths that might have been potentially survivable with prompt hemorrhage control. Similar analyses of battlefield deaths led to life-saving changes in military medical practice. STUDY DESIGN: This is a retrospective study of decedent records. The objective is to estimate the number of hemorrhagic deaths that might have been prevented by prompt placement of an extremity tourniquet. Maryland autopsy records from 2002 to 2016 were selected using the following search terms: amputation, arm/arms, avulsion, exsanguination, extremity/extremities, leg/legs. The records were analyzed by applying a checklist of previously developed military criteria to characterize deaths as potentially survivable or nonsurvivable with prompt use of a tourniquet. Suicides and decedents less than 18 years old were excluded. The study did not use information about living participants. Two expert reviewers independently evaluated and scored the death records. Deaths were classified as either potentially survivable or nonsurvivable. A third reviewer broke any ties. RESULTS: There were 288 full autopsy records included in the final analysis. Of the eligible decedents reviewed during the 14-year period, 124 of 288 had potentially survivable wounds; 164 had nonsurvivable wounds. CONCLUSIONS: Over the 14-year study interval, 124 Maryland decedents-an average of 9 per year-might have been saved with prompt placement of a tourniquet. If extrapolated, approximately 480 people in the US might be saved per year. These results provide evidence to support educating and equipping the public to provide bleeding control.

Effect of Emergency Physician-Performed Point-of-Care Ultrasound and Radiology Department-Performed Ultrasound Examinations on the Emergency Department Length of Stay Among Pregnant Women at Less Than 20 Weeks' Gestation.

OBJECTIVES: We sought to confirm retrospective studies that measured an approximately 20% reduction in emergency department (ED) length of stay (LOS) in early-gestation pregnant women who receive emergency physician-performed point-of-care ultrasound (US) examinations rather than radiology department-performed US examinations for evaluation of intrauterine pregnancy (IUP). METHODS: A randomized controlled clinical trial was performed at an urban academic safety net hospital and 2 Naval medical centers in the United States. The allocation was concealed before enrollment. Clinically stable adult pregnant women at less than 20 weeks' gestation who presented to the ED with abdominal pain or vaginal bleeding were randomized to receive a point-of-care or radiology US to assess for IUP. The primary outcome measure was the ED LOS. RESULTS: A total of 224 patients (point-of-care US, n = 118; radiology US, n = 106) were included for the analysis. The ED LOS was 20 minutes shorter in the point-of-care US arm (95% confidence interval [CI], -54 to 7 minutes). Adjusting for variability due to the location, the ED LOS was calculated to be 31 minutes shorter (95% CI, -64 to 1 minute) than for patients in the radiology US arm. Excluding patients in the point-of-care US arm who crossed over to radiology US after an inconclusive point-of-care US examination, the ED LOS was 75 minutes shorter than in the radiology US arm (95% CI, -97 to -53 minutes). CONCLUSIONS: Early-gestation pregnant ED patients requiring pelvic US were discharged earlier when point-of-care US was used rather than radiology US; however, this trial did not achieve our target of 30 minutes. Nevertheless, our data support the routine use of ED point-of-care US for IUP, saving the most time if a conclusive IUP is identified.

Operational Point-of-Care Ultrasound Review: Low-Cost Simulators and Resources for Advanced Prehospital Providers.

Prehospital ultrasound use is a relatively new skill set. The military noted the clear advantages of this skill set in the deployed setting and moved forward with teaching their advanced combat trauma medics skills to perform specific examinations. The training curriculum for Special Operations-level clinical ultrasound was created and adapted from training guidelines set forth by the American College of Emergency Physicians with a focus on the examinations relevant to the Special Operations community. Once providers leave the training environment, skill sustainment can be difficult. We discuss the relevant ultrasound exams for the prehospital setting. We address opportunities to improve point-of-care ultrasound skills through hands-on experience while in a fixed medical facility. Options for simulation-based training are discussed with descriptions for creating low-cost simulation models. Finally, a list of online resources is provided to review specific ultrasound examinations.

Bedside emergency ultrasound in a case of acute parotid duct sialolithiasis.

BACKGROUND: Sialolithiasis with salivary gland obstruction can mimic more frequently occurring illnesses such as facial and dental infection and abscess. It is often difficult to discern the etiology of facial pain and swelling on physical examination alone, requiring advanced imaging in the emergency department. CASE REPORT: We describe the case of a 37-year-old man who presented with 5 days of worsening unilateral facial pain and swelling. Use of bedside emergency ultrasound by an emergency physician (EP) led to an appropriate diagnosis of parotid duct sialolithiasis. Why Should an Emergency Physician Be Aware of This? Use of bedside emergency ultrasound performed by a trained EP successfully diagnosed symptomatic sialolithiasis of the parotid duct in the emergency department without the need for computed tomography. The utility of bedside emergency ultrasound in the evaluation of sialolithiasis and the outcomes of our case are discussed here.

E-point septal separation: a bedside tool for emergency physician assessment of left ventricular ejection fraction.

OBJECTIVES: Rapid assessment of left ventricular ejection fraction (LVEF) may be critical among emergency department (ED) patients. This study examined the predictive relationship between ED physician performed bedside mitral-valve E-point septal separation (EPSS) measurements to the quantitative, calculated LVEF. We further evaluated the relationship between ED physician visual estimates of global cardiac function (GCF) and calculated LVEF values. METHODS: A prospective observational study was conducted on a sequential convenience sample of patients receiving comprehensive transthoracic echocardiography (TTE). Three ED ultrasound fellows performed bedside ultrasound examinations to obtain both EPSS measurements and subjective visual GCF estimates. A linear regression analysis was conducted to examine the relation of EPSS to the calculated LVEF from the comprehensive TTE. Agreement (modified Cohen κ) between ED ultrasound fellow GCF estimates and the calculated LVEF was also assessed. RESULTS: Linear regression analyses revealed a significant correlation (r=0.73, P<.001) between bedside EPSS and the calculated LVEF. The sensitivity and specificity of an EPSS measurement of greater than 7 mm for severe systolic dysfunction (LVEF≤30%) were 100.0% (95% confidence interval, 62.9-100.0) and 51.6% (95% confidence interval, 38.6-64.5), respectively. Subjective estimates of GCF were moderately correlated with calculated LVEF (Cohen κ=0.58). CONCLUSIONS: Measurements of EPSS by ED physicians were significantly associated with the calculated measurements of LVEF from comprehensive TTE. Subjective visual estimates of GCF, however, demonstrated only moderate agreement with the calculated LVEF. An EPSS measurement greater than 7 mm was uniformly sensitive at identifying patients with severely reduced LVEF.

Cardiac complications of adult methamphetamine exposures.

BACKGROUND: Methamphetamine use is an increasing problem in the United States. Despite the similarities to cocaine in clinical presentation, methamphetamine effects on the cardiovascular system are not as clearly understood. OBJECTIVES: The purpose of this retrospective review is to evaluate the cardiovascular outcomes of methamphetamine exposures reported to both the California Poison Control System (CPCS) and two Level 1 trauma centers. METHODS: CPCS records from 2000-2009, as well as inpatient and emergency department charts from two Level 1 trauma centers during the time frame of 2000-2004 were reviewed. Charts of adults with coded methamphetamine exposures were included. RESULTS: Records of 2356 adults with methamphetamine exposure were assigned levels of severity according to National Poison Data System Medical Outcomes Criteria. Out of the combined charts reviewed from the CPCS data and hospital registries, 584 cases were coded as minor effects, 450 as moderate effects, 208 as major effects, and 28 as deaths. Of the included 1270 cases, 627 electrocardiograms (ECGs) were analyzed. Together, troponins and ECGs showed evidence of myocardial ischemia in 82 total cases, which is 6.5% of the cases reviewed. Cocaine was a co-ingestant in 10 of the 82 cases. CONCLUSIONS: This study presents a large cohort of methamphetamine users. The study found that chest pain and myocardial ischemia were reported in a number of cases. Although no true incidence can be taken from this dataset, it provides a large-scale review of methamphetamine use and its possible association with acute coronary syndromes.

Pharmacological inhibition of the hypertensive response to combretastatin A-4 phosphate in rats.

Combretastatin A-4 phosphate (CA4P) is a novel and promising anti-neoplastic agent. However, it is associated with transient hypertension in both animal and human models. In this study, we examined the potential cardiac toxicity and hypertensive effects of CA4P, and defined the most effective pharmacological inhibition of CA4P-induced hypertension in rats. There was a significant, concentration dependent increase in mean arterial blood pressure with a maximum increase of about 60% of the baseline MAP at 30 mg/kg of CA4P compared to the saline control. However, there was no significant increase in the cardiac troponin I level after CA4P injection. Nitroglycerin and the calcium channel blocker diltiazem effectively blocked the hypertensive effects of CA4P while the beta blocker metoprolol was ineffective. Furthermore, sublingual nitroglycerin administration demonstrated an additional anti-hypertensive effect in a setting of a low dose diltiazem infusion (10 microg/kg/min). We conclude that CA4P treatment resulted in a concentration dependent increase in blood pressure without significant myocardial damage in healthy rats. The hypertensive effect of CA4P was effectively blocked by both nitroglycerin and diltiazem, but not metoprolol.

Systematic discovery of multicomponent therapeutics.

Multicomponent therapies, originating through deliberate mixing of drugs in a clinical setting, through happenstance, and through rational design, have a successful history in a number of areas of medicine, including cancer, infectious diseases, and CNS disorders. We have developed a high-throughput screening method for identifying effective combinations of therapeutic compounds. We report here that systematic screening of combinations of small molecules reveals unexpected interactions between compounds, presumably due to interactions between the pathways on which they act. Through systematic screening of approximately 120,000 different two-component combinations of reference-listed drugs, we identified potential multicomponent therapeutics, including (i) fungistatic and analgesic agents that together generate fungicidal activity in drug-resistant Candida albicans, yet do not significantly affect human cells, (ii) glucocorticoid and antiplatelet agents that together suppress the production of tumor necrosis factor-alpha in human primary peripheral blood mononu-clear cells, and (iii) antipsychotic and antiprotozoal agents that do not exhibit significant antitumor activity alone, yet together prevent the growth of tumors in mice. Systematic combination screening may ultimately be useful for exploring the connectivity of biological pathways and, when performed with reference-listed drugs, may result in the discovery of new combination drug regimens.