Cannabinoid Hyperemesis Encounters After Medical Legalization in Oklahoma.

Introduction Medical cannabis has recently become legal in Oklahoma. Cannabinoid hyperemesis syndrome (CHS) is severe nausea, vomiting, and often abdominal pain typically seen in heavy users of cannabis. The aim of this study is to determine whether emergency department (ED) diagnoses of CHS have increased after medical legalization. Methods We performed a retrospective chart review study of equivalent time periods prior to and after the first legal sales of medical cannabis in Oklahoma. Data were gathered from a single urban ED of adult patients with diagnosed or suspected CHS. We analyzed data using a chi-square analysis of CHS cases as a proportion of total ED visits. Results Diagnosed and suspected CHS visits increased from 43 cases in the eight months preceding the first legal sale to 62 cases in the eight months after legalization. This represents a statistically significant increase in ED visits for CHS (p = 0.026). Total ED encounters were 30,437 and 28,362, respectively, during those time periods. The proportion of visits for CHS was much higher (220/100000 vs 13.3/100000) than previously reported in the literature. The pre-legalization and post-legalization groups did not differ by age, sex, history of GI illness and diabetes, pregnancy, or other drug use. Conclusion We observed a statistically significant increase in ED visits for CHS after the first legal sales of medical cannabis in Oklahoma. Our high proportion of ED visits for CHS could be related to study design, increased provider awareness, high THC levels in Oklahoma's medical cannabis, or increased numbers of cannabis users after legalization. Increases in ED visits for CHS and other cannabinoid-related illnesses must be weighed against the positive effects for cannabis users by policymakers.

Use of nares swab to de-escalate vancomycin for patients with suspected methicillin-resistant Staphylococcus aureus.

Introduction: According to the US Center for Disease Control and Prevention, 30%-50% of antibiotic use in hospitals is unnecessary or inappropriate. The coronavirus disease 2019 pandemic further complicates antibiotic use leading to greater initiation of empiric antibiotics. The result is antibiotic overuse and increased duration of unnecessary therapy. Vancomycin is a drug of last resort, primarily relegated to the treatment of Methicillin-Resistant Staphylococcus aureus (MRSA). De-escalating vancomycin can mean waiting on MRSA culture results, which may take up to 96 h. Nares screening for MRSA is shown to possess high negative predictive value for ruling out suspected MRSA pneumonia, intra-abdominal infections, and bacteremia. Methods: This before-and-after study examines the impact of vancomycin therapy de-escalation due to absence of MRSA colonization detected via PCR assay of nares swabs. An intervention with providers using SMART goals was designed to increase nasal swabbing for MRSA and ultimately decrease vancomycin use at a large, tertiary-care urban hospital. Results: There was a significant increase in use of vancomycin nares swabs (28/150 vs 48/100, p = 0.040) in the immediate pre/postintervention period, and significant decreases in vancomycin usage days/1,000 patient days of 2.34% per month (p = 0.039) over a two year period after the intervention. Conclusion: An intervention using PCR nares swabs to detect MRSA led to significant, lasting decreases in vancomycin usage at this hospital. Similar interventions should be planned at hospitals experiencing overuse of this antibiotic.

Food Is Medicine for Individuals Affected by Homelessness: Findings from a Participatory Soup Kitchen Menu Redesign.

Health disparities among people experiencing homelessness are likely exacerbated by limited access to healthy, fresh, and minimally processed foods. Soup kitchens and shelters serve as essential food safety nets for preventing hunger in this population, and community interest is growing in the potential of "food is medicine" interventions to improve the mental and physical wellbeing of people who receive meals from these providers. This study describes our two-phase approach to first identify and prioritize nutrition needs within an urban soup kitchen community and then test and implement new recipes and menu guidelines to help the standard soup kitchen menu better align with those priorities. We began by first conducting a nutrition needs assessment, including a collection of intercept surveys from a convenience sample of soup kitchen guests to better understand their nutrition-related health needs, dental issues, food preferences, and menu satisfaction (n = 112), as well as a nutrition analysis of the standard menu based on seven randomly selected meals. Most respondents reported at least one chronic health condition, with depressive disorders (50.9%) and cardiovascular diseases (49.1%) being the most common. Nearly all guests requested more fruits and vegetables at mealtimes, and results from the menu analysis revealed opportunities to lower meal contents of sodium, saturated fat, and added sugars and to raise micronutrient, fiber, and omega-3 content. We then applied these nutrition needs assessment findings to inform the second phase of the project. This phase included the identification of new food inventory items to help support cardiovascular and mental health-related nutrition needs, taste test sampling of new healthy menu items with soup kitchen guests, and hands-on culinary medicine training to kitchen staff on newly-developed "food is medicine" guidelines to support menu transformation. All taste tests of new menu items received over 75% approval, which exceeded satisfaction ratings of the standard menu collected during the phase 1 needs assessment. Findings from this community-based participatory research project confirm the great potential for hunger safety net providers to support critical nutrition needs within this vulnerable population through strategic menu changes. However, more research is needed on the longitudinal impacts of such changes on health indicators over time.

Transverse Myelitis in Naloxone Reversible Acute Respiratory Failure-A Case Report.

Transverse myelitis (TM) is a rare inflammatory myelopathy presenting as bilateral neurologic deficit localized to the spinal cord. A critical management step in the emergency department (ED) is evaluating for and treating acute reversible causes such as mass lesion or reversible ischemia when present. Described in this case report is TM presenting after a respiratory arrest in suspected opioid overdose. Magnetic resonance imaging (MRI), ideally with contrast, and lumbar puncture are essential diagnostic studies to confirm inflammation. Finally, further diagnostic efforts are aimed at evaluation and treatment for other concurrent illnesses. Topics: Transverse myelitis, transverse myelopathy, hypoxia, opioid overdose, hypoxic spinal cord injury.

An Emergency Medicine Remediation Consult Service: Access to Expert Remediation Advice and Resources.

Resident remediation is a complex and common issue in emergency medicine programs and requires a specific knowledge base. The Remediation Task Force (RTF) of the Council of Residency Directors in Emergency Medicine (CORD-EM) was created to identify remediation best practices and to develop tools for program directors. Initially housed on a Wiki page, and now located within the CORD-EM website, the RTF provides resources including accepted universal language for documentation and sample remediation plans. The RTF also created a remediation consult service composed of experienced educators to provide real-time structured feedback and advice to submitted remediation scenarios with consultation outcomes and conclusions uploaded to the website. CORD-EM members now have easy access to online resources and expert advice for remediation queries through the consult service. The combination of online resources and access to real-time expert advice is an innovative approach to improving resident remediation and recognizing best practices.

Points & Pearls: Electrical injuries in the emergency department: an evidence-based review

Electrical injuries can be caused by exposure to current from low-voltage and high-voltage sources as well as lightning strikes, and the circumstances of the exposure will dictate management strategies. Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. This issue reviews the types of trauma seen with electrical injury and how body systems can be affected by occult or delayed effects, and the optimal evidence-based resuscitation and management strategies associated with each. [Points & Pearls is a digest of Emergency Medicine Practice.]

Electrical injuries in the emergency department: an evidence-based review.

Electrical injuries can be caused by exposure to current from low-voltage and high-voltage sources as well as lightning strikes, and the circumstances of the exposure will dictate management strategies. Human tissues have varying resistance characteristics and susceptibility to damage, so injuries may be thermal, electrical, and/or mechanical, potentially causing burns, thrombosis, tetany, falls, and blast injury. This issue reviews the types of trauma seen with electrical injury and how body systems can be affected by occult or delayed effects, and the optimal evidence-based resuscitation and management strategies associated with each.

Can Emergency Medicine Residents Predict Cost of Diagnostic Testing?

INTRODUCTION: Diagnostic testing represents a significant portion of healthcare spending, and cost should be considered when ordering such tests. Needless and excessive spending may occur without an appreciation of the impact on the larger healthcare system. Knowledge regarding the cost of diagnostic testing among emergency medicine (EM) residents has not previously been studied. METHODS: A survey was administered to 20 EM residents from a single ACGME-accredited three-year EM residency program, asking for an estimation of patient charges for 20 commonly ordered laboratory tests and seven radiological exams. We compared responses between residency classes to evaluate whether there was a difference based on level of training. RESULTS: The survey completion rate was 100% (20/20 residents). We noted significant discrepancies between the median resident estimates and actual charge to patient for both laboratory and radiological exams. Nearly all responses were an underestimate of the actual cost. The group median underestimation for laboratory testing was $114, for radiographs $57, and for computed tomography exams was $1,058. There was improvement in accuracy with increasing level of training. CONCLUSION: This pilot study demonstrates that EM residents have a poor understanding of the charges burdening patients and health insurance providers. In order to make balanced decisions with regard to diagnostic testing, providers must appreciate these factors. Education regarding the cost of providing emergency care is a potential area for improvement of EM residency curricula, and warrants further attention and investigation.

Peripheral Intravenous Line Placement and Utilization in an Academic Emergency Department.

BACKGROUND: Rising health care costs and increased scrutiny concerning spending have prompted providers and hospitals to identify unnecessary procedures and waste. Peripheral intravenous line (pIV) placement is one of the most common medical procedures performed. A recent study reported that 50% of intravenous lines placed in the emergency department (ED) went unused. If half of all pIVs placed in EDs systemically go unused, the costs and complications associated with pIV placement are unacceptably high. OBJECTIVES: Our study aims to ascertain the frequency of pIV placement and usage in an urban ED. METHODS: This was a retrospective review of medical records for consecutive patients seen in an academic ED in June 2014. The following data points were recorded: age, sex, chief complaint, acuity level on admission, pIV placement both prehospital and in the ED, and pIV utilization (for fluids, medications, or contrast administration). RESULTS: There were 509 charts reviewed, with a median patient age of 40 years. Common chief complaint categories included neurologic, cardiac, and skin/soft tissue. Triage acuity was varied, with a mean of 3.3. A pIV was placed in 55% of subjects. Prehospital providers placed 19%. Of all pIVs placed, 72% were used for the administration of medications, 19% for contrast, and 67% for fluids. Eighty-five percent of pIVs were used; 51% of patients with a pIV were admitted from the ED. CONCLUSION: In this study's ED, 85% of pIVs were used prior to discharge. Strategies to lower pIV placement rates should focus on alternative routes of medication and fluid administration.