Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital.

STUDY OBJECTIVE: We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study. METHODS: We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate. RESULTS: Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure. CONCLUSION: We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

Cash critical care time prices vary substantially by region and hospital ownership: A cross-sectional study.

OBJECTIVES: Emergency department (ED) patients may be billed for critical care time (current procedural terminology codes 99291 and 99292) if they receive at least 30 min of critical care services. We sought to determine the median cash (self-pay) prices for critical care time performed in the ED in the United States and assess for associations between hospital characteristics and prices. METHODS: We performed a cross-sectional analysis of hospital cash prices for critical care time performed in the ED using the first 25 alphabetical states. For each hospital, we recorded hospital characteristics including state, control (nonprofit, governmental, or for-profit), size, teaching status, and system. We then searched for each hospital's cash prices for 99291 and 99292 using Turquoise and hospital websites. We determined the median price for 99291 nationally, regionally, and for large hospital systems. We performed multivariable quantile regression to assess for associations between hospital characteristics and prices for 99291. RESULTS: Of the 2629 eligible hospitals, 2245 (85.4%) and 1893 (72.0%) reported cash prices for 99291 and 99292, respectively. For 99291, the cash price ranged from $45 to $84,775 with a median of $1816 (IQR: $1039-3237). For 99292, the median price was $567 (IQR: $298-1008). On multivariable analysis, hospitals had higher cash prices for 99291 if they were located in the West, for-profit, or part of a large system. In particular, hospitals owned by Tenet Healthcare charged the most for 99291 (median $28,244). CONCLUSION: The cash prices for critical care time vary substantially based on hospital characteristics. In particular, for-profit hospitals and those in the West tend to charge the most. Given that patients who require critical care are unlikely to be able to choose the hospital to which they present, standardization of critical care time fees should be considered.

Discrepancies in Outcomes by Race and Ethnicity in COVID-19 Patients Receiving Casirivimab and Imdevimab.

OBJECTIVES: The Centers for Disease Control and Prevention has reported increased rates of coronavirus disease 2019 (COVID-19)-related hospitalizations and deaths in Black and Hispanic individuals. One contributing factor to this may be a difference in access to treatment. We thus sought to compare the outcomes of Black, non-Hispanic patients and Hispanic patients with White, non-Hispanic individuals using a group of patients with COVID-19 who received casirivimab/imdevimab. METHODS: This was a secondary analysis of data from a previously published retrospective chart review of patients who received casirivimab/imdevimab for COVID-19 between December 9, 2020 and August 20, 2021, when they were treated at one of three facilities within a single hospital system. We compared the baseline characteristics (including age, sex, body mass index, duration of symptoms, and vaccination status) and outcomes of Black, non-Hispanic patients and Hispanic patients with those of White, non-Hispanic patients. Our primary outcome was the odds of a return visit to the emergency department (ED) within 28 days of treatment as assessed by multivariate logistic regression. We also assessed the rates of return visits to the ED for symptoms caused by COVID-19, hospitalizations, and hospitalizations from hypoxia. RESULTS: In total, 1318 patients received casirivimab/imdevimab for COVID-19 at the three study facilities. Of these, 410 (31.1%) identified themselves as White and non-Hispanic, 88 (6.7%) as Black and non-Hispanic, and 736 (55.8%) as Hispanic. Vaccination rates at the time of treatment were as follows: Black, non-Hispanic 10.2%, Hispanic 13.6%, and White, non-Hispanic 21.5%. On multivariate analysis, the odds of return visits to the ED within 28 days were higher for Black, non-Hispanic patients and Hispanic patients as compared with White, non-Hispanic patients, with odds ratios of 2.8 (95% confidence interval [CI] 1.4-5.5, P = 0.003) and of 2.3 (95% CI 1.5-3.6, P = 0.0002), respectively. For hospitalizations caused by hypoxia within 28 days of treatment, the adjusted odds ratio for Black, non-Hispanic patients was 3.4 (95% CI 1.1-10.5, P = 0.03) as compared with White, non-Hispanic patients. There were no other statistically significant differences among groups in regard to subsequent hospitalizations within 28 days. CONCLUSIONS: Black, non-Hispanic patients and Hispanic patients are more likely to make a return visit to the ED within 28 days after casirivimab/imdevimab treatment for COVID-19 as compared with White, non-Hispanic patients. This holds true even when adjusting for higher vaccination rates among White, non-Hispanic individuals.

The use of additional imaging studies after biliary point-of-care ultrasound in the emergency department.

PURPOSE: We sought to determine the test characteristics of biliary point-of-care ultrasound (POCUS) and to assess the usefulness of obtaining radiology ultrasound (RUS) or cholescintigraphy (HIDA) after biliary POCUS. METHODS: We conducted a retrospective review of emergency department patients who underwent biliary POCUS between May 4, 2018 and November 28, 2021. To be included, patients had to have at least one of the following confirmatory evaluations (considered in this order): surgery, HIDA, RUS, or abdominal CT scan. When a discrepancy existed between the POCUS and the RUS or HIDA, they were compared to a higher criterion standard (if available). RESULTS: Using 348 patients who had a confirmatory evaluation after biliary POCUS, we found the sensitivity and specificity of biliary POCUS for gallstones to be 97.0% (95% CI 92.6 to 99.2%) and 99.5% (95% CI 97.3 to 100%), respectively. For cholecystitis, the sensitivity and specificity were 83.8% (95% CI 72.9 to 91.6%) and 98.6% (95% CI 96.4 to 99.6%), respectively. RUS and POCUS were concordant in 72 (81.8%) of 88 cases in which the patient had both studies while HIDA and POCUS were concordant in 24 (70.6%) of 34 cases. POCUS was deemed correct in at least 50% of discrepant cases with RUS and at least 30% of discrepant cases with HIDA. CONCLUSION: Biliary POCUS has excellent sensitivity and specificity for cholelithiasis; it has lower sensitivity for cholecystitis, but the specificity remains high. Performing a confirmatory RUS or cholescintigraphy after a positive biliary POCUS adds little value, but additional imaging may be useful when POCUS is negative for cholecystitis.

A Comparison of SARS-COV-2 Neutralizing Antibody Therapies in High-Risk Patients with Mild to Moderate COVID-19 Disease at a Single Academic Hospital.

BACKGROUND: Bamlanivimab and casirivimab/imdevimab are recombinant neutralizing monoclonal antibodies that decrease viral load in patients with coronavirus disease 2019 (COVID-19) and can decrease hospitalizations. Few data exist comparing these two therapies. OBJECTIVE: Our aim was to compare the efficacy and safety of bamlanivimab and casirivimab/imdevimab in emergency department (ED) patients with COVID-19 who met criteria for monoclonal antibody therapy. METHODS: We performed a single-center, open-label, prospective study in adult ED patients with confirmed COVID-19 and high-risk features for hospitalization. Enrolled patients received bamlanivimab or casirivimab/imdevimab, depending on the day of the week that they arrived. We observed patients for post-infusion-related reactions and contacted them on days 5, 10, and 30. The primary outcome was the number of hospitalizations through day 30. In addition, we compared groups with regard to return visits to the ED, symptom improvement, antibody-induced adverse events, and deaths. RESULTS: Between December 17, 2020 and January 17, 2021, 321 patients completed the study. We found no statistically significant difference in the rate of subsequent hospitalization between groups (bamlanivimab: n = 18 of 201 [8.9%] and casirivimab/imdevimab: n = 13 of 120 [10.8%]; p = 0.57). In addition, we found no statistically significant differences between groups regarding return visits to the ED or symptom improvement. One patient had a possible adverse reaction to the treatment, and 1 patient died. Both of these events occurred in the bamlanivimab group. CONCLUSIONS: We found no statistically significant differences in rates of subsequent hospitalization or other outcomes for ED patients with COVID-19 when they received bamlanivimab as opposed to casirivimab/imdevimab. Adverse events were rare in both groups.

Triage Nurse-Ordered Testing in the Emergency Department Setting: A Review of the Literature for the Clinician.

BACKGROUND: In an effort to decrease length of stay (LOS) and reduce overcrowding, many emergency departments (ED) have implemented triage nurse-ordered testing. STUDY OBJECTIVES: To review the medical literature to determine the utility of triage nurse-ordered testing and to offer evidence-based recommendations to emergency physicians. METHODS: A systematic search of the PubMed literature was performed for publication in English from inception to November 30, 2019 using a combination of the following keywords: "triage," "nurse," "protocol," and "emergency." The articles were screened for relevance and the selected studies were subjected to detailed review by all of the authors and assigned a grade of evidence based on focus, research design, and methodology. Recommendations were drawn from the findings. RESULTS: The initial search yielded a total of 982 potentially relevant studies; 13 articles were ultimately selected for inclusion. Of these, 10 studies assessed ED LOS, with one study assessing time to diagnosis. The three remaining studies compared triage nurse-ordered testing with physician testing in the ED setting. CONCLUSIONS: Triage nurses have reasonably similar accuracy as physicians in ordering limb x-ray studies and moderate accuracy for laboratory testing. However, we did not identify a clinically meaningful decrease in ED LOS from the use of nursing triage orders.

Emergency Medicine Resident-Driven Point of Care Ultrasound for Suspected Shoulder Dislocation.

OBJECTIVE: To determine the impact of implementing a musculoskeletal in-service educational intervention for emergency medicine (EM) residents on the use of point-of-care ultrasound (POCUS) to diagnose and manage shoulder dislocations in the emergency department (ED). METHODS: This study was conducted in the ED of an academic teaching hospital in Miami, Florida. It consisted of a short in-service educational intervention on how to perform and interpret POCUS, followed by an open, prospective convenience sample study in patients with clinical suspicion of shoulder dislocation. Twenty EM residents, with no prior shoulder scanning training, participated in the study. In all of the cases, the findings of the shoulder US were compared with radiographs, which were considered the reference standard. EM residents enrolled patients, and obtained and interpreted the shoulder US images. RESULTS: Seventy-eight patients were evaluated to rule out shoulder dislocation and/or fracture. Diagnosis of the dislocated shoulder was made in 55 of 78 patients, 53 of whom had anterior dislocations. Resident-driven POCUS had a sensitivity and specificity of 100% to diagnose and rule out, respectively, shoulder dislocations and relocations. There were no differences in the number of dislocations diagnosed and relocated by early and advanced EM residents. Results from a POCUS were available 22 ± 2.8 minutes sooner than x-ray for initial diagnosis and 27 ± 2.9 minutes (P < 0.0001) sooner than x-ray for assessment of reduction. CONCLUSIONS: EM resident physicians, with no previous training in shoulder US imaging, exposed to a brief in-service musculoskeletal education intervention, were able to diagnose shoulder dislocations via POCUS with high sensitivity and specificity. Shoulder US for dislocation should be a core component in EM training.

Patients' Perceptions of the Role of Physicians in Questioning and Educating in Firearms Safety: Post-FOPA Repeal Era.

OBJECTIVES: In this study, we determined patients' attitudes toward discussing firearms and issues of firearms safety with emergency department physicians. We assessed whether patients feel discriminated against should physicians discuss firearms safety, and whether they believed that physician counseling may change how patients store firearms. METHODS: From June to October 2017, we conducted a cross-sectional institutional review board-approved survey of 200 consenting adult patients (convenience sample) not requiring critical care presenting to the emergency department of Mount Sinai Medical Center in Miami Beach, Florida. The survey consisted of 22 questions about perceptions of physicians inquiring about firearms, demographics, firearms statistics, and firearms knowledge. Results on firearms owners and nonowners were compared with the Fisher exact test. P < 0.05 was considered significant. RESULTS: Ninety percent of patients said they felt comfortable discussing firearms safety with a physician (firearms vs no firearms owner, 100% vs 87.5%, P = 0.028). Ninety percent (firearms 90.7% vs no firearms owners 89.9%, P = 1.0) of patients did not believe that physicians were discriminating against patients who are firearms owners when discussing firearms safety. Seventy-six percent (firearms 76.4% vs no firearms owners 77.3%, P = 0.367) of patients believed that physicians should be educating their patients about firearms safety, and 71% (n = 142) believed that education provided by physicians will change how people store their firearms (firearms 75% vs no firearms owners 70.2%, P = 0.67). CONCLUSIONS: Firearms safety is a difficult but important public health matter that requires significant intervention to help prevent future firearms incidents. This study supports physicians' efforts to help educate patients about the dangers of firearms, along with proper firearms storage techniques, showing that patients are largely open to this discussion. We propose that training of physicians in strategies for initiating clinical discourse and addressing firearms safety is needed.

Annotated Guidance and Recommendations for the Role and Actions of Emergency Medical Services Systems in the Current Opioid and Drug-Related Epidemics.

BACKGROUND: The U.S. and worldwide death toll from opioids and other drugs has accelerated, rivaling all other causes of premature death. Emergency medical services (EMS) now has an evolving role in providing solutions. METHODS: EMS medical directors from the majority of the largest U.S. cities and global counterparts met to share/compile an inventory of best practices derived from their respective high-volume experiences in jurisdictions with >114 million residents combined. In turn, they created a consensus guideline document for the purposes of information-sharing among themselves and other interested parties. RESULTS: The group concluded that EMS personnel have evolving training needs with respect to new medical care challenges, but they also recommended that agencies have a special place within the collective of those hoping to provide solutions to the public health crisis of addiction and drug-related epidemics. In addition to intervening in real-time overdose events, it was recommended that they partner with other key stakeholders to develop mechanisms to end the repetitive cycle of emergency rescue followed by an almost immediate return to addictive behaviors. EMS providers should be trained to optimally communicate, refer, and direct the affected individuals to appropriate resources that will provide viable and evidence-based pathways directed toward long-term recovery. CONCLUSIONS: Beyond a need to update acute medical rescue practices and improved assessment techniques, EMS providers should also learn to optimally communicate, encourage, and even participate in facilitating management continuity for the affected individuals by identifying and using the appropriate resources that will provide viable, evidence-based pathways toward sustained recovery.

Pericardial Herniation of Small Bowel Post Minimally Invasive Hybrid Maze of Atrial Fibrillation.

BACKGROUND: Herniation of intraabdominal contents into the pericardial cavity is exceptionally rare, and when seen, it is most often the result of trauma, postsurgical complication, or genetic defect. There have been only a few case reports describing spontaneous bowel herniation into the pericardium in minimally invasive cardiac procedures like cardiac ablation, pacemaker placement, and minimally invasive coronary artery bypass graft. CASE REPORT: We report the case of a 65-year-old man who presented to an urgent care center complaining of abdominal and chest pain. This patient had recently undergone a laparoscopic hybrid maze procedure and ultimately had an incarcerated loop of small bowel herniate into the pericardial sac. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the diagnosis of a pericardial hernia in patients presenting with gastrointestinal or cardiorespiratory symptoms after surgical procedures involving the diaphragm.

Assessment of Trauma Team Activation Fees by US Region and Hospital Ownership.

Importance: Trauma centers must be readily equipped to handle a variety of life-threatening injuries and consequently may charge a fee for the activation of their trauma team. Regional and hospital-related variations in trauma activation fees across the US have not been formally assessed. Objective: To evaluate the variability of trauma activation fees from trauma centers across the US and examine whether certain hospital characteristics are associated with higher activation fees. Design, Setting, and Participants: This cross-sectional study used data from the American College of Surgeons website to identify all trauma centers in the US that were listed as verified from inception of the verification database through March 4, 2022 (N = 546). Five military hospitals were excluded, and trauma activation fees could not be found for 18 trauma centers; the remaining 523 hospitals were included in the analysis. Each hospital's publicly available chargemaster (a comprehensive list of a hospital's products, procedures, and services) was searched to obtain its trauma activation fees. Two levels of trauma activation fees were recorded: tier 1 (full activation) and tier 2 (partial activation). Hospital-specific data were obtained from the American Hospital Association website. All data were collected between January 2 and March 11, 2022. Linear regression analyses were performed to assess potential associations between hospital characteristics (type of control [for profit, government, church, or other nonprofit], hospital system [owner], number of staffed beds, and academic vs nonacademic status) and trauma activation fees. Main Outcomes and Measures: Median and mean trauma activation fees nationally and stratified by location, hospital system, and other hospital characteristics. Results: Of 523 trauma centers included in the analysis, most were located in the Midwest (180 centers) and West (129 centers). There were 176 adult level I trauma centers and 200 adult level II trauma centers; 69 centers had for-profit status, and 415 were academic. Overall, the median (IQR) tier 1 trauma activation fee was $9500 ($5601-$17 805), and the mean (SD) tier 1 trauma activation fee was $13 349 ($11 034); these fees ranged from $1000 to $61 734. Median (IQR) trauma activation fees were highest in the West ($18 099 [$10 741-$$27 607]), especially in California, where the median (IQR) activation fee was $24 057 ($15 979-$33 618). Trauma activation fees were also higher at for-profit hospitals, most of which were owned by the HCA Healthcare system, which had 43 trauma centers and a median (IQR) tier 1 trauma activation fee of $29 999 ($20 196-$37 589). Conclusions And Relevance: In this study, trauma activation fees varied widely among hospitals in the US. Regional variation in these fees was substantial, with hospitals in the West charging substantially more than those in other locations. In addition, for-profit hospitals charged more than other types of hospitals. These findings suggest that some patients with serious traumatic injuries will incur disproportionately high trauma activation fees depending on the trauma center to which they are brought. Therefore, standardization of trauma activation fees is warranted.

The Implementation of a Prehospital Whole Blood Transfusion Program and Early Results.

INTRODUCTION: In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future. OBJECTIVE: A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results. METHODS: This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team's perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute. FINDINGS: From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit's shelf life prior to transfusion. CONCLUSION: Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.

A Case of Transvaginal Small Bowel Evisceration following Hysterectomy with Discussion of Emergency Department Diagnosis and Management.

Transvaginal small bowel evisceration is a rare surgical emergency that requires urgent surgery to prevent bowel necrosis, sepsis, and death. It was first reported in 1864 by Hyernaux with less than 100 cases reported since the original publication. The overall mortality rate is reported as 5.6 percent. We present the case of a 49-year-old woman who presented to the emergency department with a chief complaint of moderate abdominal pain and vaginal bleeding for 1 hour. The patient reported that she underwent a robotic-assisted laparoscopic hysterectomy 11 weeks prior for uterine fibroids. Visual examination revealed a loop of the small bowel coming from the superior aspect of her vagina. Literature reviews have noted a higher incidence of dehiscence following robotic-assisted total laparoscopic hysterectomy. It is important for the emergency physician to make the diagnosis, initiate prompt consultation with departments of obstetrics and gynecology and general surgery, and treat for potential infection.

Ectopic glandular breast tissue in a lactating young woman.

BACKGROUND: Ectopic breast tissue is a rare occurrence in pregnant women and should not be confused with abscess or other causes. Ectopic breast tissue is present at birth but often only diagnosed after puberty, pregnancy, or lactation. OBJECTIVE: Misdiagnosis is of concern due to the fact that ectopic breast tissue may undergo pathological changes with increased risk of malignancy. Therefore, it is vital for emergency physicians to be able to recognize this process and ensure proper follow-up care. CASE REPORT: We present a case of ectopic breast tissue in a 19-year-old primigravida. CONCLUSION: Surgical removal for the purpose of prophylaxis of malignant changes is not currently recommended. Definitive diagnosis is established by fine-needle aspiration and excisional biopsy.

Cocaine-induced agitated delirium with associated hyperthermia: a case report.

BACKGROUND: "Cocaine-induced agitated delirium with associated hyperthermia" is a rare, almost uniformly fatal syndrome. The incidence of the disease is not known, however, it is believed to have markedly increased since the late 1980s with widespread popularity of crack cocaine. OBJECTIVE: Recent literature is lacking regarding this rare syndrome. Although almost uniformly fatal, we present a neurologically intact survivor due to a multidisciplinary team approach. CASE REPORT: We are reporting a 41-year-old African-American man who arrived at the trauma center with a rectal temperature of 42.6°C (108.6°F) and a toxicology screen positive for cocaine. The patient manifested many of the known complications of cocaine-induced agitated delirium with associated hyperthermia, including renal failure and coagulation panel abnormalities. With early application of cooling techniques, including ice pack, gastric lavage, and bilateral chest cavity lavage using multiple chest tubes, the patient's core temperature was quickly lowered. CONCLUSION: This case demonstrated how a multidisciplinary team approach, including emergency medicine and critical care specialists, and aggressive treatment of hyperthermia using bilateral tube thoracostomy and chest cavity lavage enabled our patient's core temperature to be effectively lowered. We were unable to find prior reports of using tube thoracostomy in this manner.

Clinical Considerations in Initial Evaluation and Treatment of Hardhead Catfish Spine Puncture Wounds.

A 17-year-old male presented to our ED complaining of pain and swelling at the base of the first metacarpal after attempting to remove a catfish from his fishing line 12 hours prior to arrival. Radiographic images demonstrated a foreign body (FB), which was detectable by ultrasound. Hand surgery was consulted and took the patient to the operating room for exploration and removal of two serrated radiopaque catfish spines that were deeply embedded in the left thumb. Conclusion. Penetrating injury from hardhead catfish (Ariopsis felis) spines can cause hidden FB, envenomation, infection, and secondary damage to nearby structures. Imaging should be done for these patients to ensure they obtain timely and complete extraction of the venomous structures. Surgery should be consulted for operative management to avoid damage on removal of the catfish spine remnants.

Emergency Physician Survey on Firearm Injury Prevention: Where Can We Improve?

INTRODUCTION: Firearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention. The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED). METHODS: We conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate. RESULTS: A total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home. CONCLUSIONS: Among respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.

Negative Whole-Body Computed Tomography Scans in Polytrauma Patients: A Retrospective Cohort Study.

BACKGROUND: Whole-body computed tomography (WBCT) has been a mainstay and an integral part of the evaluation of polytrauma patients in trauma centers and emergency departments (ED) for a comprehensive evaluation of the extent of injuries. However, routine use of WBCT remains controversial since it exposes patients to radiation and exponentially increases financial expense. The primary objective was to determine the rate of negative WBCT in polytrauma patients. PATIENTS AND METHODS: A retrospective cohort study was conducted at an academic hospital in the Kingdom of Saudi Arabia, which is a dedicated trauma center with a mean of 237,392 ED visits and 10,714 trauma per year. The study included all adult (≥18 years) polytrauma patients who presented to our ED, requiring trauma team activation, and underwent WBCT as part of their evaluation from January 2016 to May 2017. We excluded pediatric patients, patients transferred from another facility, and pregnant patients. The primary endpoint was to measure the rate of negative WBCT in polytraumatized patients. RESULTS: A total of 186 patients were included with a mean age of 28.8 ± 12.9 years. The rate of negative WBCT scans was 20.4%. The positive scans were subclassified based on the number of anatomical body regions that were affected radiologically. One body region was affected in 47 patients (31.8%), two body regions were affected in 50 patients (33.8%), and ≥3 body regions were affected in 51 patients (34.3%). In a subset analysis, we identified that oxygen saturation <94% and GCS ≤8 were associated with positive CT scans. CONCLUSION: Our study revealed a slightly higher rate of utilization of WBCT in the management of trauma patients compared to studies with similar practice. We believe that in the correct setting with incorporating high index of suspicion, a physical examination with attention to vital signs and mental status, performing E-FAST, and dedicated X-Rays is a way to potentially reduce the use of WBCT in polytrauma patients.