Utilization of the Disaster Medical Assistance Team (DMAT) in an Inner-City Emergency Department During the COVID-19 Pandemic.

OBJECTIVE: To evaluate the effect of the Disaster Medical Assistance Team (DMAT) in an inner-city emergency department during the coronavirus disease (COVID-19) pandemic. METHODS: Data were abstracted from individual emergency department encounters over 6 weeks. The study compared left without being seen (LWBS) percentage, door-to-provider, and door-to-disposition times for 2 weeks before, during, and after the DMAT. RESULTS: The LWBS percentages for the 2 weeks before and after the DMAT were 16.2% and 11.6%, respectively. The LWBS percentage during the DMAT was 8.1%. Door-to-disposition times for the 2 weeks before and after the DMAT were 7.36 hours and 8.53 hours, respectively. The door-to-disposition during the DMAT was 7.33 hours. Door-to-disposition was statistically significant during the 2 weeks of the DMAT compared to the 2 weeks after the DMAT (7.33 vs 8.53, P < 0.05) but not statistically significant when compared to the period before the DMAT (7.36 vs 7.33, P = 1.00). Door-to-provider time was the longest during the DMAT (122.5 minutes [2.04 hours]) when compared to the time frame before the DMAT (114.54 minutes [1.91 hours]) and after the DMAT (102.84 minutes [1.71 hours]). CONCLUSION: The DMAT had the most positive impact on LWBS percentages. The DMAT showed no improvement in door-to-provider times in the study and only in door-to-disposition times when comparing the time the DMAT was present to after the DMAT departed.

Does Mixing Activated Charcoal With Cola Improve Tolerability Without Affecting Pharmacokinetics? A Randomized Controlled Crossover Trial.

INTRODUCTION: Activated charcoal is the most common form of gastrointestinal decontamination used for the poisoned patient. One limitation to its use is patient tolerability due to palatability. Some recommend mixing activated charcoal with cola to improve palatability. An important question is whether mixing activated charcoal with cola affects the ability of the activated charcoal to adsorb xenobiotic. METHODS: This was a prospective randomized controlled crossover trial. Five healthy adults aged 18 to 40 years were recruited. Participants received 45 mg/kg acetaminophen rounded down to the nearest whole tablet. One hour later, they were randomized to receive 50 g of an activated charcoal-water premixture alone or mixed with cola. Acetaminophen levels were collected. The area under the curve of acetaminophen concentrations over time was measured as a marker for degree of absorption. Participants also completed an appeal questionnaire in which they rated the activated charcoal preparations. Participants would then return after at least 7 days to repeat the study with the other activated charcoal preparation. RESULTS: Four male participants and 1 female participant were recruited. There was no statistical difference in preference score for activated charcoal alone versus the cola-activated charcoal mixture. There was no statistical difference in the area under the curve of acetaminophen concentrations over time between activated charcoal alone and the cola-activated charcoal mixture. Of note, the study is limited by the small sample size, limiting its statistical power. DISCUSSION: The absorption of acetaminophen in an overdose model is no different when participants received activated charcoal alone or a cola-activated charcoal mixture as suggested by area under the curve. In this small study, there was no difference in preference for activated charcoal alone or a cola-activated charcoal mixture across a range of palatability questions. On an individual level, some participants preferred the activated charcoal-cola mixture, and some preferred the activated charcoal alone.

Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi.

Objectives: Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT. Methods: This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT. Results: Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of >4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49). Conclusion: Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of >4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.

Effect of a targeted quality improvement education on opioid prescribing.

BACKGROUND: The opioid epidemic is a serious social, economic and public health problem. This study was designed to evaluate the effectiveness of individual institutional opioid prescriber training on prescriber adherence to the Centers for Disease Control and Prevention (CDC's) guidelines for responsible opioid prescribing practices to treat acute pain. METHODS: Opioid prescribing data were collected from an academic medical centre and its associated outpatient clinics. A baseline for opioid prescribing practices was collected for 2 years and 2 months prior to the planned intervention. Departments responsible for 5% or more of the total institutional opioid prescriptions were chosen to study in detail. A number of opioid prescriptions per department per day and their compliance with the maximum daily dose (MDD) recommendations put out by the CDC were determined. INTERVENTION: The hospital administration implemented a mandatory opioid prescriber training as part of their standard annual provider education for all medical staff, who were all required to attest having read it and pass a quiz by 30 September 2019, which was chosen as the end date for the pre-intervention data. Data were analysed preintervention and postintervention to assess the effect of this intervention on opioid prescribing. RESULTS: Overall opioid prescribing rates decreased by 18.3% and there were significant decreases in opioid prescribing rate in five out of the seven departments/divisions. Overall, there was a statistically significant decrease in the compliance with MDD before (71.3%) and after (67.3%) the intervention (4%, 95% CI 3.13% to 4.87% difference, p<0.001). Additionally, there were statistically significant increases in compliance with CDC guidelines in three departments/divisions. However, there was a statistically significant decrease in compliance with CDC guidelines after intervention in two departments. CONCLUSIONS: The results of this study were largely encouraging for the effectiveness of this institutional mandatory prescriber training.

Are Pediatric Manual Resuscitators Only Fit for Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance.

Background: The manual resuscitator device is the most common method of ventilating patients with respiratory failure, either with a facemask, or with an advanced airway such as an endotracheal tube (ETT). Barotrauma and gastric inflation from excessive ventilation volumes or pressure are concerning complications. Ventilating adult patients with pediatric manual resuscitator may provide more lung-protective tidal volumes based on stationary patient simulations. However, use of a pediatric manual resuscitator in mobile simulations contradictorily generates inadequate tidal volumes.Methods: Sixty-two emergency medical services (EMS) clinicians in a moving ambulance ventilated a manikin using pediatric and adult manual resuscitators in conjunction with oral-pharyngeal airway, i-gel, King LTS-D, or an endotracheal tube.Results: Oral-pharyngeal airway data were discarded due to EMS clinician inability to produce measurable tidal volumes. Mean ventilation volumes using the pediatric manual resuscitator were inadequate compared to those with the adult manual resuscitator on all other airway devices. In addition, i-gel, King LTS-D, and endotracheal tube volumes were statistically comparable. Paramedics ventilated larger volumes than emergency medical technicians.Conclusions: Using a pediatric manual resuscitator on adult patients is not supported by our findings.

Pilot study: Utility of long-wave infrared thermography as a correlate to transcutaneous oximetry for candidates of hyperbaric oxygen therapy.

Hyperbaric oxygen (HBO2 ) has been used as an adjunctive treatment for the care of advanced non-healing diabetic foot ulcers (DFUs). A patient's in-chamber transcutaneous oximetry measurement (TCOM) is currently the most effective predictor for response to HBO2 therapy but still excludes close to one in four patients who would benefit out of treatment groups when used for patient selection. Improving selection tools and criteria could potentially help better demonstrate HBO2 therapy's efficacy for such patients. We sought to identify if long-wave infrared thermography (LWIT) measurements held any correlation with a patient's TCOM measurements and if LWIT could be used in a response prediction role for adjunctive HBO2 therapy. To investigate, 24 patients already receiving TCOM measurements were enrolled to simultaneously be imaged with LWIT. LWIT measurements were taken throughout each patient's therapeutic course whether they underwent only standard wound care or adjunctive HBO2 treatments. A significant correlation was found between in-chamber TCOM and post-HBO2 LWIT. There was also a significant difference in the post-HBO2 LWIT measurement from 1st treatment to 6 weeks or the last treatment recorded. These initial findings are important as they indicate a possible clinical use for LWIT in the selection process for patients for HBO2 therapy. Larger studies should be carried out to further articulate the clinical use of LWIT in this capacity.

Patients' Perspectives on Emergency Department COVID-19 Vaccination and Vaccination Messaging Through Randomized Vignettes.

OBJECTIVES: Emergency departments (EDs) could play an important role in the COVID-19 pandemic response by reaching patients who would otherwise not seek vaccination in the community. Prior to expanding COVID-19 vaccination to the acute care setting, we assessed ED patients' COVID-19 vaccine status, perspectives, and hypothetical receptivity to ED-based vaccination. METHODS: From January 11 through March 31, 2021, we conducted a multisite (Albany Medical Center, Boston Medical Center, Buffalo General Hospital, University of Cincinnati Medical Center, and Upstate Medical Center), cross-sectional survey of ED patients, with embedded randomization for participants to receive 1 of 4 vignette vaccination messages (simple opt-in message, recommendation by the hospital, community-oriented message, and acknowledgment of vaccine hesitancy). Main outcomes included COVID-19 vaccination status, prior intention to be vaccinated, and receptivity to randomized hypothetical vignette messages. RESULTS: Of 610 participants, 122 (20.0%) were vaccinated, 234 (38.4%) had prior intent to be vaccinated, 111 (18.2%) were unsure as to prior intent, and 143 (23.4%) had no prior intent to be vaccinated. Vaccine hesitancy (participants who were vaccine unsure or did not intend to receive the vaccine) was associated with the following: age <45 years, female, non-Hispanic Black, no primary health care, and no prior influenza vaccination. Overall, 364 of 565 (64.4%; 95% CI, 60.3%-68.4%) were willing to accept a hypothetical vaccination in the ED. Among participants with prior vaccine hesitancy, a simple opt-in message resulted in the highest acceptance rates to hypothetical vaccination (39.7%; 95% CI, 27.6%-52.8%). CONCLUSIONS: EDs have appropriate patient populations to initiate COVID-19 vaccination programs as a supplement to community efforts. A simple opt-in approach may offer the best messaging to reach vaccine-hesitant ED patients.

Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH): a pragmatic registry of large vessel occlusion stroke patients to create evidence-based stroke systems of care and eliminate disparities in access to stroke care.

BACKGROUND: Large vessel occlusion (LVO) strokes are best treated with rapid endovascular therapy (EVT). There are two routes that LVO stroke patients can take to EVT therapy when transported by EMS: primary transport (ambulance transports directly to an endovascular stroke center (ESC) or secondary transport (EMS transports to a non-ESC then transfers for EVT). There is no clear evidence which path to care results in better functional outcomes for LVO stroke patients. To find this answer, an analysis of a large, real-world population of LVO stroke patients must be performed. METHODS: A pragmatic registry of LVO stroke patients from nine health systems across the United States. The nine health systems span urban and rural populations as well as the spectrum of socioeconomic statuses. We will use univariate and multivariate analysis to explore the relationships between type of EMS transport, socioeconomic factors, and LVO stroke outcomes. We will use geographic information systems and spatial analysis to examine the complex movements of patients in time and space. To detect an 8% difference between groups, with a 3:1 patient ratio of primary to secondary transports, 95% confidence and 80% power, we will need approximately 1600 patients. The primary outcome is the patients with modified Rankin Scale (mRS) ≤ 2 at 90 days. Subgroup analyses include patients who receive intravenous thrombolysis and duration of stroke systems. Secondary analyses include socioeconomic factors associated with poor outcomes after LVO stroke. DISCUSSION: Using the data obtained from the OPUS-REACH registry, we will develop evidence based algorithms for prehospital transport of LVO stroke patients. Unlike prior research, the OPUS-REACH registry contains patient-level data spanning from EMS dispatch to ninety day functional outcomes. We expect that we will find modifiable factors and socioeconomic disparities associated with poor outcomes in LVO stroke. OPUS-REACH with its breadth of locations, detailed patient records, and multidisciplinary researchers will design the optimal prehospital stroke system of care for LVO stroke patients.

Impact of COVID-19 on Emergency Medicine Residency Programs: A Cross-Sectional Study in New York State.

INTRODUCTION: The 2019 novel coronavirus pandemic has caused significant disruptions in the clinical operations of hospitals as well as clinical education, training, and research at academic centers. New York State was among the first and largest epicenters of the pandemic, resulting in significant disruptions across its 29 emergency medicine (EM) residency programs. We conducted a cross-sectional observational study of EM residency programs in New York State to assess the impact of the pandemic on resident education and training programs. METHODS: We surveyed a cross-sectional sample of residency programs throughout New York State in June 2020, in the timeframe immediately after the state's first "wave" of the pandemic. The survey was distributed to program leadership and elicited information on pandemic-prompted curricular modifications and other educational changes. The survey covered topics related to disruptions in medical education and sought details on solutions to educational issues encountered by programs. RESULTS: Of the 29 accredited EM residency programs in New York State, leadership from 22 (76%) responded. Of these participating programs, 11 (50%) experienced high pandemic impact on clinical services, 21 (95%) canceled their own trainees' off-service rotations, 22 (100%) canceled or postponed visiting medical student rotations, 22 (100%) adopted virtual conference formats (most within the first week of the pandemic wave), and 11 (50%) stopped all prospective research (excluding COVID-19 research), while most programs continued retrospective research. CONCLUSION: This study highlights the profound educational impact of the pandemic on residency programs in one of the hardest- and earliest-hit regions in the United States. Specifically, it highlights the ubiquity of virtual conferencing, the significant impact on research, and the concerns about canceled rotations and missed training opportunities for residents, as well as prehospital and non-physician practitioner trainees. This data should be used to prompt discussion regarding the necessity of alternate educational modalities for pandemic times and the sequelae of implementing these plans.

Identifying possible surrogate markers of COVID19 as a supplement to diagnostic testing in Upstate New York.

INTRODUCTION: COVID19 has raised concerns for resource allocation across various sectors of healthcare. At the frontlines, emergency departments are required to triage a wide range of acuity and non-specific symptomology. METHODS: This retrospective study aimed to pave the way for more concrete detection and triage of patients by analyzing symptomology, physical findings, diagnostic testing and relevant hospital course of the 458 suspected cases that initially presented to an academic level one trauma center emergency department between March and August 2020. A total of 202 COVID positive cases were analyzed. RESULTS: The most common symptoms were cough (70.63%), fatigue (77%), and shortness of breath (59%). There was a significantly higher percentage of abnormal chest imaging in inpatient groups compared to the ED discharge group (42.86% vs 79%, p < 0.01). Laboratory studies, especially markers of inflammation (CRP, ESR), markers of tissue damage (lactic acid, troponin), and markers of infection were markedly higher and above normal reference ranges in complicated cases (p < 0.01). While there is limited data on the sensitivity and specificity of the current nasopharyngeal PCR test, there was no permutation of symptoms, physical findings, diagnostic testing that was more sensitive than that of the current PCR test calculated at 66.1% in our cohort. CONCLUSION: Laboratory studies that otherwise are more commonly conducted inpatient, including markers of inflammation, tissue damage, and infection, may be useful in disposition planning of ED patients in conjunction with clinical correlation of presentation and chest imaging.

Bridge clinic buprenorphine program decreases emergency department visits.

INTRODUCTION: Opioid withdrawal due to opioid use disorder (OUD) is an increasing health emergency and complaint in emergency departments (EDs) across the United States. As a response to the increased need for OUD treatment, a low threshold buprenorphine program, or Bridge Clinic, was established within our hospital system. Patients are primarily connected to the Bridge Clinic through the ED, and are able to complete their consultation appointment reliably within 1-3 days of referral. This program also serves to connect patients to community resources for continued treatment of OUD. METHODS: A retrospective chart review was performed to identify ED-based referrals to the Bridge Clinic in the period from January 1, 2017 - December 31, 2018. Outcomes of interest included: (1) ED utilization in the six months before and after consultation at the Bridge Clinic and (2) adherence to buprenorphine therapy at 2-year follow-up. RESULTS: A total of 269 patients were included in the study, with 167 males (62%) and a mean age of 37.8 years. There were 654 total visits to the ED six months before referral to the Bridge Clinic and 381 visits in the six-month period after the initial appointment. There was a high adherence to buprenorphine treatment at 2 year follow up (56%). CONCLUSIONS: These early results suggest that prompt referral to a buprenorphine treatment program significantly reduces ED utilization and connects patients to community resources for continued buprenorphine treatment for OUD.

An assessment of urine THC immunoassay in healthy volunteers receiving an oral proton-pump inhibitor.

Introduction: Limitations of urine drug-screening (UDS) by immunoassay include false-positive results. Pantoprazole, a proton-pump inhibitor (PPI), is reported to cause false-positive results for THC on UDS. The objective of this study was to determine if oral PPIs cause false-positive THC results using the THC One Step Marijuana Test Strip®.Methods: Eligible healthy volunteers completed a 5-day course of a PPI followed by urine testing using the THC One Step Marijuana Test Strip®. Phase one included 3 subjects taking pantoprazole 40 mg once daily for 5 days. On day 5, urine specimens underwent THC screening. Phase two included 9 subjects randomized to 5-day supply of once-daily oral esomeprazole 20 mg, lansoprazole 15 mg, or omeprazole 20 mg. All study methods and testing mirrored those in phase one.Results: All 12 subjects completed the study protocol. All urine samples collected on day 5 were negative for THC in all subjects.Discussion: Our results demonstrate that oral PPIs did not cause a false-positive THC using the THC One Step Marijuana Test Strip®. Limitations include small sample size, use of a single commercial immunoassay, and inability to confirm medication compliance. Further, large-scale research using other commercial urine immunoassays is warranted.

Naloxone Administration by Untrained Community Members.

STUDY OBJECTIVE: Access to naloxone is a priority for reducing opioid deaths. Although community members who complete naloxone training are able to administer nasal naloxone successfully and rapidly, little is known about the ability of community members to administer naloxone without training. The objective of this study was to assess the ability of untrained individuals to administer naloxone successfully in a simulated opioid overdose setting. DESIGN: Prospective single-site open-label randomized usability assessment. SETTING: Scenario station at a large state fair during August and September 2017. PARTICIPANTS: A total of 207 healthy adults who were randomly assigned to administer naloxone using a nasal spray (NS) device (69 participants), an intramuscular (IM) kit (68 participants), or an improvised nasal atomizer (AT) kit (70 participants). INTERVENTION: Participants were instructed to administer the device to a high-fidelity mannequin in a public environment with distractions to mimic those that might be present in an actual overdose. No device instructions or administration materials were provided. MEASUREMENTS AND MAIN RESULTS: Participants were assessed by trained study team members who directly observed all naloxone administrations using the predetermined end-point criteria. Individual participant perceptions were evaluated immediately following the naloxone administration using a standardized questionnaire form. The primary outcome was successful administration, defined as administration within 7 minutes and without critical errors. Secondary outcomes were time to successful naloxone administration and ease of use of the device. The NS (66.7%, p<0.001) and IM (51.5%, p<0.001) devices had higher rates of successful administration than the improvised nasal AT device (2.9%). The NS device was administered more rapidly (median 16 sec) than the IM device (median 58 sec, p<0.001) or improvised nasal AT device (median 113 sec, p=0.012) devices, and it was the easiest to use. CONCLUSION: In this study of naloxone administration, participants administered the NS and IM devices more successfully than the AT device. The NS device was administered most rapidly and was easiest to use.

Sonographic Detection of Cutaneous Myiasis.

Cutaneous maggots are occasionally encountered in the emergency department. We present a case in which maggots were visually identified and ultrasound was used to detect additional maggots below the skin crevices in a patient with elephantiasis nostras verrucosa.

Blood glucose levels in diabetic patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: To determine if hyperbaric oxygen (HBO2) therapy has an effect on diabetic blood glucose levels (BGL) and, if so, the extent of this effect. Also, to examine factors that exacerbate any observed effect. METHODS: This was a retrospective review of prospectively collected quality data on diabetics undergoing HBO2. Pre- and post-treatment BGL were recorded. Pre-treatment BGL ⟨120 mg/dL received glucose supplementation. Hypoglycemia was defined as BGL ⟨70 mg/dL. BGL ⟨90 mg/dL was included as an elevated hypoglycemia threshold. RESULTS: 77 patients representing 1,825 treatments were included for analysis. No patient had deleterious side effects or required emergency care. BGL decreased in 75.4% of treatments in this group, with a median decrease of 25 mg/dL (IQR=54 mg/dL; range of decreased 374 mg/dL to increased 240 mg/dL). A statistically significant greater percentage of treatments of patients with type 2 diabetes resulted in a decrease in BGL (1598 or 77.5%) compared to treatments of patients with type 1 diabetes (169 or 51.5%) (χ2(1, N=1767) =55.37, p⟨0.001). 1.1% of treatments had post-HBO2 serum glucose ⟨90 mg/dL, and 0.2% of treatments had post-HBO2 serum glucose ⟨70 mg/dL. The majority (70%) of patients with post-HBO2 BGL ⟨90 mg/dL were maintained on insulin alone (χ2(2, N=20) =12.4, p=0.002). Well-controlled diabetics (i.e., those with all BGLs within 50 mg/dL over all pre-HBO2 treatments) had no post-HBO2 BGL ⟨70 mg/dL or ⟨90 mg/dL. CONCLUSION: Our results suggest that HBO2 does not cause a clinically significant decrease in diabetic patient BGL. No patient in our study had deleterious side effects or required emergency care. We found that glucose level of ⟨90 mg/dL occurred more often in those who use insulin. Hyperbaric patients who exhibit consistent BGL values may represent a group who could be managed similarly to the non-diabetic population.

Use of in-chamber transcutaneous oxygen measurement to determine optimal treatment pressure in patients undergoing hyperbaric oxygen therapy.

INTRODUCTION: Hyperbaric oxygen (HBO2) therapy is used to promote healing in select problem wounds. Transcutaneous oxygen measurement (TCOM) can be used to predict the response of these wounds to HBO2, with in-chamber TCOM values shown to be the most predictive. We evaluated the use of in-chamber TCOM values to determine optimal treatment pressure. METHODS: A retrospective review was completed of patients undergoing HBO2 therapy for a lower-extremity wound and who had in-chamber TCOM. Data collected included TCOM values, treatment profile, and patient outcome. RESULTS: A total of 142 patients were identified. The overall results demonstrated healing in 59%, minor amputation (below ankle) in 11.3%, and major amputation (above ankle) in 16.2% of patients. 79.3% of patients at 2 atmospheres absolute (ATA) and 86.6% of patients at 2.4 ATA had transcutaneous oxygen pressure (TcPO2) values ≥250 mmHg. Among those with TcPO2 ⟨250 mmHg at 2 ATA, 41% attained TcPO2 ⟩250 mmHg at 2.4 ATA. Among those treated at 2 ATA the healing rate was 70.6% if TcPO2 ⟩250 mmHg, and 11.8% if TcPO2 ⟨250 mmHg (P⟨0.001). Among those treated at 2.4 ATA the healing rate was 33.3% if TcPO2 ⟩250 mmHg and 14.3% if TcPO2 ⟨250 mmHg (P⟨0.001). DISCUSSION: Determining optimal therapeutic pressure for patients undergoing HBO2 is important to maximize benefit and minimize risk. This study indicates that in-chamber TCOM can be used to select an individualized optimal treatment pressure in patients undergoing HBO2 for lower-extremity wounds, including diabetic foot ulcers. This may result in better utilization of HBO2 and better outcomes.

A randomized usability assessment of simulated naloxone administration by community members.

BACKGROUND AND AIMS: Expanded access to naloxone has been identified as a key intervention for reducing opioid-related morbidity and mortality. It is not known which naloxone device will result in rapid, successful administration when administered by community members. The aims of this study were to estimate and compare (1) the rate of successful administration and (2) time to successful administration for single-step nasal spray, multi-step atomized nasal spray and intramuscular simulated naloxone by community members. DESIGN: A prospective, single-site, open-label, randomized usability assessment of simulated naloxone administration in a convenience sample of community members. Participants were randomized to single-step nasal spray (SP), multi-step atomized nasal spray (AT) or intramuscular simulated (IM) naloxone and asked to administer the simulated medication to a mannequin after completing a 2-minute training video. SETTING: New York, USA at a state fair that attracts between 60 000 and 120 000 individuals daily. PARTICIPANTS: A total of 138 participants completed the study over a 2-day period in September 2016. All participants were at least 18 years of age and had no prior naloxone training. MEASUREMENTS: The rate of successful administration and time to successful administration were recorded for each device. FINDINGS: The SP device (100%; P < 0.001) had a higher rate of success compared with the IM device (69.6%). Although success differed between the AT (89.1%) device and IM device, as well as the AT device and SP device, these differences were not significant. The SP device also had a shorter median time to successful administration (34.3 sec) compared with the IM (99.9 sec; P < 0.001) and AT (110.3; P < 0.001) devices. CONCLUSIONS: After video training, community members are able to (1) administer single-step nasal spray naloxone with a higher rate of success than intramuscular naloxone in a simulated overdose setting and (2) administer single-step nasal spray naloxone more rapidly than both intramuscular and multi-step atomized nasal spray naloxone.

Physicians' understanding of CT probabilities in ED patients with acute abdominal pain.

OBJECTIVE: Computerized tomography (CT) is often employed to diagnose or rule out certain suspected abdominal pathologies. The aim of this study is to compare emergency physicians' estimated post-test disease probabilities to the probabilities obtained for similar diagnostic tests as reported in the literature. METHODS: Physicians were asked to estimate pre and posttest probabilities before and after CT scan results in patients with nontraumatic abdominal and pelvic pain. The actual post-test probability was calculated using published likelihood ratios and compared to physician judgment. RESULTS: 210 patient encounters were included. In the negative CT group, physicians' median pre-test probability was 40% with a post-test probability of 0%, while the actual post-test probability is 4.2% (p<0.001). Physicians' median pre-test probability for a positive CT was 70% with a post-test probability of 100%, while the actual post-test probability is 98% (p<0.001). The diverticulitis subgroup had no significant differences between physician and actual post-test probabilities. The post-op abscess subgroup had significant differences in post-test probabilities in both the negative CT (30% difference, p=0.028) and positive CT subgroups (-37% difference, p=0.003). CONCLUSIONS: When applying the probability theory of disease, physicians tend to overestimate the power of CT scanning. The difference in physician and actual post-test probabilities may be small or not clinically significant in diseases with good positive and negative likelihood ratios such as in diverticulitis; however, this difference may be large and clinically significant in diseases with poor likelihood ratios such as in post-op abscess.