Anyone Anytime for Anything: The History of Emergency Medicine in Missouri.

The history of Emergency Medicine (EM) in Missouri reflects the larger history of EM as a burgeoning specialty throughout the United States, but with some important and unique contributions that may not be generally appreciated. We discuss historical events and important leaders of EM, but there are many we could not mention. Much of the information comes from personal interviews with the physicians who "were in the room where it happened.". We hope the article will illuminate the progress made in caring for critical illness and injury through the development of a new specialty focused on that goal. We recognize there are many emergency physicians not mentioned that have played a large role in maintaining and growing the academic programs, improving the delivery of care through administrative and legislative actions, and navigating the specialty through enormously challenging times.

Clinical Outcomes of a Pharmacomechanical Catheter-Directed Venous Thrombolysis Strategy that Included Rheolytic Thrombectomy in a Multicenter Randomized Trial.

PURPOSE: To describe the clinical outcomes of a pharmacomechanical catheter-directed venous thrombolysis (PCDT) strategy that included AngioJet rheolytic thrombectomy. METHODS: In the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis multicenter randomized trial, physicians at 33 sites designated AngioJet as their preferred device for PCDT. In these sites, 364 patients with acute proximal lower-extremity deep vein thrombosis (DVT) were randomized to a strategy of PCDT that incorporated either AngioJet along with anticoagulation or anticoagulation alone. Relief from presenting DVT symptoms was evaluated over 30 days of follow-up. Postthrombotic syndrome (PTS), quality of life (QOL), recurrent venous thromboembolism (VTE), and safety were evaluated over 24 months of follow-up. RESULTS: Within 30 days, AngioJet-PCDT led to a greater improvement in leg swelling (mean difference calf circumference 0.55 cm, P = .009), venous QOL (mean difference 6.5 Venous Insufficiency Epidemiologic and Economic Study [VEINES]-QOL points, P = .0073), and venous symptoms (mean difference 5.6 VEINES-symptoms points, P = .0134) than control, with differences most apparent in iliofemoral DVT. AngioJet-PCDT reduced PTS at 6 months (24% with AngioJet-PCDT vs 40% with control, P = .003) but did not influence PTS or QOL between 12 and 24 months. Major bleeding, pulmonary embolism, renal failure, and bradycardia were infrequent with AngioJet-PCDT (<2% each), but 24-month VTE recurrence may have been more frequent (13.9% with AngioJet-PCDT vs 6.8% with control, P = .03) CONCLUSIONS: In patients with acute proximal DVT, a treatment strategy that included first-line AngioJet-PCDT was reasonably safe and led to an improved symptom status and venous QOL at 1 month and reduced PTS at 6 months compared with anticoagulation alone. However, AngioJet-PCDT did not influence PTS or the QOL beyond 6 months and may have increased recurrent VTE.

Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis.

BACKGROUND: The post-thrombotic syndrome frequently develops in patients with proximal deep-vein thrombosis despite treatment with anticoagulant therapy. Pharmacomechanical catheter-directed thrombolysis (hereafter "pharmacomechanical thrombolysis") rapidly removes thrombus and is hypothesized to reduce the risk of the post-thrombotic syndrome. METHODS: We randomly assigned 692 patients with acute proximal deep-vein thrombosis to receive either anticoagulation alone (control group) or anticoagulation plus pharmacomechanical thrombolysis (catheter-mediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting). The primary outcome was development of the post-thrombotic syndrome between 6 and 24 months of follow-up. RESULTS: Between 6 and 24 months, there was no significant between-group difference in the percentage of patients with the post-thrombotic syndrome (47% in the pharmacomechanical-thrombolysis group and 48% in the control group; risk ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.11; P=0.56). Pharmacomechanical thrombolysis led to more major bleeding events within 10 days (1.7% vs. 0.3% of patients, P=0.049), but no significant difference in recurrent venous thromboembolism was seen over the 24-month follow-up period (12% in the pharmacomechanical-thrombolysis group and 8% in the control group, P=0.09). Moderate-to-severe post-thrombotic syndrome occurred in 18% of patients in the pharmacomechanical-thrombolysis group versus 24% of those in the control group (risk ratio, 0.73; 95% CI, 0.54 to 0.98; P=0.04). Severity scores for the post-thrombotic syndrome were lower in the pharmacomechanical-thrombolysis group than in the control group at 6, 12, 18, and 24 months of follow-up (P<0.01 for the comparison of the Villalta scores at each time point), but the improvement in quality of life from baseline to 24 months did not differ significantly between the treatment groups. CONCLUSIONS: Among patients with acute proximal deep-vein thrombosis, the addition of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not result in a lower risk of the post-thrombotic syndrome but did result in a higher risk of major bleeding. (Funded by the National Heart, Lung, and Blood Institute and others; ATTRACT ClinicalTrials.gov number, NCT00790335 .).

A Bridge to Nowhere? Challenging Outpatient Transitions of Care for Acute Pain Patients in the Opioid Epidemic Era.

Opioid misuse is reducing Americans' life expectancy, thereby catalyzing professional societies and legislators to action. Efforts to combat the opioid epidemic must work hand-in-hand with appropriate efforts to reduce the severity and duration of suffering. Pharmacologic analgesia is temporizing. Current opioid prescribing guidelines focus on reducing the frequency and quantity of narcotics prescribed, but lack attention to alleviation of the source of pain. Conditions eliciting acute pain sometimes require additional specialist management following discharge from the emergency department. Patients frequently lack timely access to these specialists, particularly if underinsured. This essay explores acute dental pain, extremity fractures, and back pain as three common examples whereby complex healthcare systems must efficiently adapt in order to serve the dual objectives of reducing the risk of opioid-related adverse consequences and minimizing the duration of patient suffering.

The Opioid Crisis in Missouri: A Call to Action for Physicians, Legislators, and Society.

Opioid overdose deaths in the United States increased sharply over the last decade leading the President to declare a national emergency. The neurobiology of opioid addiction is explored in conjunction with the historical events preceding the current epidemic. A patient-centric perspective is provided along with rationale for contemporary Medical Assisted Therapy (MAT) options to safely reduce overdose deaths and other preventable consequences of prescription misuse and heroin abuse. A multidisciplinary medical provider approach is essential, in addition to legislative efforts to reduce current regulatory burdens that reduce access to MAT in many settings. This review introduces a new Missouri Medicine series intended to explore key concepts to simultaneously reduce opioid prescribing, while effectively managing acute and chronic pain across complex healthcare settings.

Improving Emergency Department Care for Aging Missourians: Guidelines, Accreditation, and Collaboration.

Aging baby-boomers present significant challenges to accessible, affordable emergency care in America for patients of all ages. St. Louis physicians served as early innovators in the field of geriatric emergency medicine. This manuscript summarizes a multi-institutional November 2016 symposium reviewing the Missouri history of geriatric emergency care. In addition, this manuscript describes multispecialty organizations' guidelines, healthcare outcomes research, contemporary medical education paradigms, and evolving efforts to disseminate guideline-based geriatric emergency care using a "Boot Camp" approach and implementation science. This manuscript also reviews local adaptations to emergency medical services and palliative care, as well as the perspectives of emergency department leaders exploring the balance between infrastructure and personnel required to promote guideline-based geriatric emergency care with the anticipated benefits. This discussion is framed within the context of the American College of Emergency Physician's planned geriatric emergency department accreditation process scheduled to begin in 2018.

Ecallantide for the acute treatment of angiotensin-converting enzyme inhibitor-induced angioedema: a multicenter, randomized, controlled trial.

STUDY OBJECTIVE: We compare the safety and efficacy of ecallantide with placebo in subjects undergoing assessment for acute angiotensin-converting enzyme inhibitor-induced angioedema (ACEIA) in an emergency department (ED). METHODS: This was a multicenter, phase 2, double-blind study with subjects randomized to receive a single subcutaneous dose of ecallantide (10, 30, or 60 mg) or placebo plus physician-directed conventional therapy. The primary endpoint was defined as meeting predetermined discharge eligibility criteria within 6 hours of study drug administration. Discharge criteria included improvement of edema, stable vital signs, absence of stridor, absence of dyspnea or use of accessory muscles during respiration, absence of drooling, and ability to drink without difficulty. RESULTS: An interim analysis showed that a high percentage of subjects met the primary endpoint, and the study was halted. Overall, 79 subjects were randomized and 76 had data for analysis. Most had mild (45%) or moderate (42%) ACEIA. The discharge eligibility endpoint was met by 72% of the placebo group and 85%, 89%, and 89% of the ecallantide 10-, 30-, and 60-mg groups, respectively. This difference in meeting discharge eligibility endpoint criteria between treatment groups was not statistically significant. The incidence of treatment-emergent adverse events was similar between placebo and active-treatment groups. CONCLUSION: The addition of ecallantide to standard therapy does not appear to improve angioedema compared with placebo in ED patients with ACEIA. Our data suggest that most ED patients presenting with mild to moderate ACEIA are likely to meet our discharge eligibility criteria within 6 hours of treatment, regardless of intervention. Further studies to assess the utility of ecallantide in patients with more severe angioedema may be useful. No new safety signals related to ecallantide administration were identified.

ChatGPT provides inconsistent risk-stratification of patients with atraumatic chest pain.

BACKGROUND: ChatGPT-4 is a large language model with promising healthcare applications. However, its ability to analyze complex clinical data and provide consistent results is poorly known. Compared to validated tools, this study evaluated ChatGPT-4's risk stratification of simulated patients with acute nontraumatic chest pain. METHODS: Three datasets of simulated case studies were created: one based on the TIMI score variables, another on HEART score variables, and a third comprising 44 randomized variables related to non-traumatic chest pain presentations. ChatGPT-4 independently scored each dataset five times. Its risk scores were compared to calculated TIMI and HEART scores. A model trained on 44 clinical variables was evaluated for consistency. RESULTS: ChatGPT-4 showed a high correlation with TIMI and HEART scores (r = 0.898 and 0.928, respectively), but the distribution of individual risk assessments was broad. ChatGPT-4 gave a different risk 45-48% of the time for a fixed TIMI or HEART score. On the 44-variable model, a majority of the five ChatGPT-4 models agreed on a diagnosis category only 56% of the time, and risk scores were poorly correlated (r = 0.605). CONCLUSION: While ChatGPT-4 correlates closely with established risk stratification tools regarding mean scores, its inconsistency when presented with identical patient data on separate occasions raises concerns about its reliability. The findings suggest that while large language models like ChatGPT-4 hold promise for healthcare applications, further refinement and customization are necessary, particularly in the clinical risk assessment of atraumatic chest pain patients.

Rationale and design of the ATTRACT Study: a multicenter randomized trial to evaluate pharmacomechanical catheter-directed thrombolysis for the prevention of postthrombotic syndrome in patients with proximal deep vein thrombosis.

BACKGROUND: Current standard therapy for patients with acute proximal deep vein thrombosis (DVT) consists of anticoagulant therapy and graduated elastic compression stockings. Despite use of this strategy, the postthrombotic syndrome (PTS) develops frequently, causes substantial patient disability, and impairs quality of life. Pharmacomechanical catheter-directed thrombolysis (PCDT), which rapidly removes acute venous thrombus, may reduce the frequency of PTS. However, this hypothesis has not been tested in a large multicenter randomized trial. STUDY DESIGN: The ATTRACT Study is an ongoing National Institutes of Health-sponsored, Phase III, multicenter, randomized, open-label, assessor-blinded, parallel two-arm, controlled clinical trial. Approximately 692 patients with acute proximal DVT involving the femoral, common femoral, and/or iliac vein are being randomized to receive PCDT + standard therapy versus standard therapy alone. The primary study hypothesis is that PCDT will reduce the proportion of patients who develop PTS within 2 years by one-third, assessed using the Villalta Scale. Secondary outcomes include safety, general and venous disease-specific quality of life, relief of early pain and swelling, and cost-effectiveness. CONCLUSION: ATTRACT will determine if PCDT should be routinely used to prevent PTS in patients with symptomatic proximal DVT above the popliteal vein.

Angioedema: etiology, pathophysiology, current and emerging therapies.

BACKGROUND: Angioedema (AE) is characterized by nonpitting edema of the dermis and subcutaneous layers. The most common sites of involvement are the tongue, lips, face, and throat; however, swelling can also occur in the extremities, genitalia, and viscera. Life-threatening airway swelling can also occur. AE may be allergic or nonallergic. The overall lifetime incidence of AE is reported to be as high as 15%. OBJECTIVE: This article summarizes the etiology, pathophysiology, and current treatment of several forms of nonallergic AE (including hereditary, acquired, and idiopathic AE) and focuses on angiotensin-converting enzyme inhibitor-induced angioedema (ACEi-AE), which is responsible for 30%-40% of all AE seen in United States emergency departments. DISCUSSION: Although the triggers, which are primary biologic mechanisms, and treatments for ACEi-AE may differ from those of the hereditary and acquired forms of AE, the clinical effects of ACEi-AE are mediated through a shared pathway, the kallikrein-kinin system. Thus, although current therapeutic options for ACEi-AE are limited, recent advances in the treatment of hereditary AE (HAE) appear promising for improving the outcomes of patients with ACEi-AE. CONCLUSIONS: New HAE medications that correct imbalances in the kallikrein-kinin system may prove safe and efficacious in the treatment of ACEi-AE.

Racial disparity in emergency department triage.

BACKGROUND: Previous reports of lower triage acuity scores and longer Emergency Department (ED) wait times for African Americans compared to Caucasians had insufficient information to determine if this was due to bias or appropriately based on medical history and clinical presentation. OBJECTIVE: (1) Determine if African Americans are assigned lower triage acuity scores (TAS) after adjusting for a number of demographic and clinical variables likely to affect triage scores. (2) Determine if lower TAS translate into clinically significant longer wait times to assignment to a treatment area. METHODS: This was a retrospective matched cohort design analysis of de-identified data extracted from the ED electronic medical record system, which included demographic and clinical information, as well as TAS, and ED process times. Triage scores were assigned using a 5-point scale (ESI), with 1 being most urgent and 5 being least urgent. Mean TAS and wait times to a treatment area for specific chief complaints were compared by race; after adjusting for age, gender, insurance status, time of day, day of week, presence of co-morbidities, and abnormal vital signs using a 1:1 matched case analysis. RESULTS: The overall mean TAS for African Americans was 2.97 vs. 2.81 for Caucasians (difference of 0.18; p<0.001), translating to a lower acuity rating. African Americans had a significantly longer wait time to a treatment area compared to case-matched Caucasians (10.9min; p<0.001), with much larger differences in wait times noted within certain specific chief complaint categories. CONCLUSION: Our current study supports the hypothesis that racial bias may influence the triage process.

Customizing anaphylaxis guidelines for emergency medicine.

BACKGROUND: Most episodes of anaphylaxis are managed in emergency medical settings, where the cardinal signs and symptoms often differ from those observed in the allergy clinic. Data suggest that low recognition of anaphylaxis in the emergency setting may relate to inaccurate coding and lack of a standard, practical definition. OBJECTIVE: Develop a simple, consistent definition of anaphylaxis for emergency medicine providers, supported by clinically relevant consensus statements. DISCUSSION: Definitions of anaphylaxis and criteria for diagnosis from current anaphylaxis guidelines were reviewed with regard to their utilization in emergency medical settings. The agreed-upon working definition is: Anaphylaxis is a serious reaction causing a combination of characteristic findings, and which is rapid in onset and may cause death. It is usually due to an allergic reaction but can be non-allergic. The definition is supported by Consensus Statements, each with referenced discussion. For a positive outcome, quick diagnosis and treatment of anaphylaxis are critical. However, even in the emergency setting, the patient may not present with life-threatening symptoms. Because mild initial symptoms can quickly progress to a severe, even fatal, reaction, the first-line treatment for any anaphylaxis episode--regardless of severity--is intramuscular injection of epinephrine into the anterolateral thigh; delaying its administration increases the potential for morbidity and mortality. When a reaction appears as "possible anaphylaxis," it is generally better to err on the side of caution and administer epinephrine. CONCLUSION: We believe that this working definition and the supporting Consensus Statements are a first step to better management of anaphylaxis in the emergency medical setting.

Elevated levels of serum glial fibrillary acidic protein breakdown products in mild and moderate traumatic brain injury are associated with intracranial lesions and neurosurgical intervention.

STUDY OBJECTIVE: This study examines whether serum levels of glial fibrillary acidic protein breakdown products (GFAP-BDP) are elevated in patients with mild and moderate traumatic brain injury compared with controls and whether they are associated with traumatic intracranial lesions on computed tomography (CT) scan (positive CT result) and with having a neurosurgical intervention. METHODS: This prospective cohort study enrolled adult patients presenting to 3 Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of 9 to 15. Control groups included normal uninjured controls and trauma controls presenting to the emergency department with orthopedic injuries or a motor vehicle crash without traumatic brain injury. Blood samples were obtained in all patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for GFAP-BDP (nanograms/milliliter). RESULTS: Of the 307 patients enrolled, 108 were patients with traumatic brain injury (97 with GCS score 13 to 15 and 11 with GCS score 9 to 12) and 199 were controls (176 normal controls and 16 motor vehicle crash controls and 7 orthopedic controls). Receiver operating characteristic curves demonstrated that early GFAP-BDP levels were able to distinguish patients with traumatic brain injury from uninjured controls with an area under the curve of 0.90 (95% confidence interval [CI] 0.86 to 0.94) and differentiated traumatic brain injury with a GCS score of 15 with an area under the curve of 0.88 (95% CI 0.82 to 0.93). Thirty-two patients with traumatic brain injury (30%) had lesions on CT. The area under these curves for discriminating patients with CT lesions versus those without CT lesions was 0.79 (95% CI 0.69 to 0.89). Moreover, the receiver operating characteristic curve for distinguishing neurosurgical intervention from no neurosurgical intervention yielded an area under the curve of 0.87 (95% CI 0.77 to 0.96). CONCLUSION: GFAP-BDP is detectable in serum within an hour of injury and is associated with measures of injury severity, including the GCS score, CT lesions, and neurosurgical intervention. Further study is required to validate these findings before clinical application.

Patterns and factors associated with intensive use of ED services: implications for allocating resources.

AIM: This study aims to better understand the patterns and factors associated with the use of emergency department (ED) services on high-volume and intensive (defined by high volume and high-patient severity) days to improve resource allocation and reduce ED overcrowding. METHODS: This study created a new index of "intensive use" based on the volume and severity of illness and a 3-part categorization (normal volume, high volume, intensive use) to measure stress in the ED environment. This retrospective, cross-sectional study collected data from hospital clinical and financial records of all patients seen in 2001 at an urban academic hospital ED. RESULTS: Multiple logistic regression models identified factors associated with high volume and intensive use. Factors associated with intensive days included being in a motor vehicle crash; having a gun or stab wound; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. Factors associated with high-volume days included falling from 0 to 10 ft; being in a motor vehicle crash; arriving during the months of January, April, May, or August; and arriving during the days of Monday, Tuesday, or Wednesday. CONCLUSION: These findings offer inputs for reallocating resources and altering staffing models to more efficiently provide high-quality ED services and prevent overcrowding.

Sonographic assessment of jugular venous distension and B-type natriuretic peptide levels in patients with dyspnoea.

BACKGROUND: Sonographic assessment of jugular venous distension (US-JVD) has been described as a sensitive test for pulmonary oedema on chest x-ray in patients with dyspnoea, but chest x-ray may not detect all patients with raised B-type natriuretic peptide (BNP) levels. OBJECTIVE: To compare US-JVD and initial BNP levels in patients with dyspnoea. METHODS: This was a secondary analysis of a previously collected dataset from a prospective study of US-JVD in patients with dyspnoea due to suspected congestive cardiac failure. Initial BNP levels were obtained for each patient. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and likelihood ratios (LR) of US-JVD ≥8 cm H(2)O for BNP ≥500 pg/ml were calculated. The product moment correlation coefficient between US-JVD and BNP was also calculated. RESULTS: 119 patients were included in the initial study. US-JVD ≥8 cm H(2)O had a sensitivity of 100% (95% CI 92% to 100%), specificity of 43% (95% CI 31% to 56%), PPV of 61% (95% CI 50% to 71%), NPV of 100% (95% CI 84% to 100%), LR+=1.75 (95% CI 1.41 to 2.17), and LR-=0 for a BNP ≥ 500 pg/ml. The Pearson correlation coefficient between US-JVD and BNP was 0.35 (95% CI 0.18 to 0.50) and the Spearman correlation coefficient was 0.73 (95% CI 0.63 to 0.80), suggesting a monotonic, but non-linear relationship between US-JVD and BNP. CONCLUSION: US-JVD correlates with initial BNP levels and is a sensitive test for raised BNP levels in patients with dyspnoea due to suspected congestive cardiac failure.

Mental health care utilization at a free drop-in youth center in St. Louis, Missouri.

We review demographic and mental health data from 1,729 youths aged 13 to 24 who attended the SPOT (Supporting Positive Opportunities with Teens), a free multi-resource drop-in youth center in St. Louis, within an 18-month period. Logistic regression analysis showed an association of increased mental health utilization and younger age, male gender, unemployment, lower educational attainment, having Medicaid, drug problems, and HIV positive status. Decreased mental health utilization was associated with black or mixed ethnicity, and living with a roommate.

Incidence of Emergency Department Visits for Electric Rental Scooters Using Detailed Ridership Data.

INTRODUCTION: Electric scooter (e-scooter) rental usage has increased exponentially around the country, expanding to more than 120 cities by the end of 2018. Early attempts to capture the safety effects of widespread adoption of this technology have been hampered by lack of accurate ridership data. Here we describe a 17-month evolution of ridership characteristics in St. Louis, Missouri, and the frequency of e-scooter rental-related injuries serious enough to require an emergency department (ED) visit over this time frame; we also provide estimates of incidence rates of injuries based on company ridership data. METHODS: We performed a combination retrospective chart review and prospective questionnaire-based analysis of adult e-scooter rental-related ED visits in both downtown St. Louis Level 1 trauma centers during the first 17 months of e-scooter rental usage (August 2018-December 2019). The retrospective portion focused on demographics, alcohol use, helmet use, disposition, operative repair, and temporal and severity markers. The prospective portion focused on more detailed crash and rider data. Finally, we used ridership data from both e-scooter rental companies in St. Louis to estimate incidence and temporal trends. RESULTS: A total of 221 patients had e-scooter rental-related ED visits. The median age of our population was 31 years with 58.8% male and 53.8% White. There were no deaths. Ninety-two patients were found to have fractures with 38% requiring surgery. Of the 21 patients diagnosed with head injury, five had an intracranial bleed. Overall incidence of ED visits related to e-scooters was 2.1 per 10,000 trips and 2.2 per 10,000 miles with the number of ED visits by month closely correlated with the number of rides per month (Pearson correlation coefficient = 0.95). CONCLUSION: The number of e-scooter rental-related injuries seen in St. Louis trauma centers was relatively low and correlated closely with overall number of rides. The number of injuries decreased and were less severe from 2018 to 2019 with infrequent intracranial injuries and a large percentage of fractures requiring operative repair.