Implementation of a Rapid Post-Code Debrief Quality Improvement Project in a Community Emergency Department Setting.

CONTEXT: Regular debriefing has been associated with improved resource utilization and measurable improvements in team performance in crisis situations. While Emergency Department (ED) staff have often stated that they would like to be provided a formal debriefing model after "code blue" and similar events, few EDs have such protocols in place. METHODS: The study consisted of two data collection processes: (1) completion of a 7-item survey distributed pre-intervention, 6-months post-intervention, and 1-year post-intervention, and (2) completion of a Rapid Post-Code Debriefing form. Overall responses were measured on a possible 0-10 scale and individual responses were tracked. The debrief process was triggered by one of four criteria and followed a standard format using a readily available form. RESULTS: A total of 178 pre- and post-debriefing protocol implementation survey responses were collected throughout the duration of the study. Of those, 79 (44.4%) were pre-protocol response surveys. The post-protocol responses were comprised of 51 (51.5%) six month and 48 (48.5%) 12-month surveys. The average overall satisfaction with code-response performance increased significantly following the implementation of the debriefing protocol, from M=6.661, SD=2.028 to M=7.90, SD=1.359 (independent t-test = 5.069, p<0.001). There was a statistically significant decrease regarding how respondents felt emotionally supported after a code by their staff, (Pearson Chi Square 14.977, df 4, p = 0.005). CONCLUSION: During this study, implementation of a post-code debriefing resulted in increased overall satisfaction with how codes had been conducted and there was a significant change in how staff felt in regards to code team leaders and an expectation of "returning to work." However, there a noted overall decrease in perceptions of feeling supported by other staff involved during the code. Further studies in both community and academic-based ED settings are needed to further explore these complex relationships.

An 84-Year-Old Man with Acute Atraumatic Compartment Syndrome of the Upper Extremity Due to Streptococcus pyogenes Cellulitis.

BACKGROUND Acute compartment syndrome represents a surgical emergency to restore blood supply by fasciotomy and decompression. Compartment syndrome is most commonly associated with crush-related injuries and fractures; however, other non-traumatic etiologies can occur. This report illustrates a rare case of acute atraumatic compartment syndrome of the upper extremity due to Streptococcus pyogenes cellulitis in an 84-year-old man, presenting a challenging clinical scenario. CASE REPORT An 84-year-old man presented to the Emergency Department with 24 h of significant right-arm pain and swelling. Due to the amount of increased swelling and significant pain, compartment pressure was obtained. He underwent emergency fasciotomy of his right forearm, hand, and carpal tunnel release. Both blood and intraoperative wound cultures grew Streptococcus pyogenes (Group A Streptococcus). The patient suffered a prolonged hospital course requiring multiple subsequent surgeries and eventual skin grafting. Despite his complicated hospital course, he made a remarkable recovery and was discharged home in excellent condition. CONCLUSIONS This report illustrates that compartment syndrome should be considered as a complication of cellulitis in patients with severe pain, even without a history of trauma. Early diagnosis, antibiotic therapy, and emergency fasciotomy are required to preserve the affected limb.

Bisphosphonate-related Femoral Shaft Fracture.

The efficacy of using bisphosphonate therapy to treat osteoporotic patients is becoming more widely known, but the potential side effects may not be. While this class of drugs is generally safe, concerns have emerged regarding risks of atypical subtrochanteric fractures associated with long-term use. There have been a number of case reports discussing the association of patients on bisphosphonates who suffer a non-traumatic or a low-energy mechanism of injury atypical of subtrochanteric fractures. The purpose of this case report is to raise awareness of this potential side effect and provide increased clinical suspicion for this rare type of fracture.

Are Emergency Medicine Residents Provided Adequate Training in Patient-Centered Communication?: A Resident Survey.

CONTEXT: Emergency Medicine residents frequently face challenging communication situations. Little is known regarding resident comfort level and amount of training received in managing these types of patient care scenarios. The purpose of this study was to measure the relationships between Emergency Medicine resident comfort levels, reported amount of patient-centered communication training received and correlation between amount of GME training and comfort levels when handling difficult situations in emergency departments. METHODS: In 2016, the authors used the Council of Emergency Medicine Residency Directors (CORD) listserv to disseminate an online survey to Emergency Medicine residents. Survey content came from the Patient Centered Communication subsection of The American Board of Emergency Medicine Milestones. This survey included five different patient scenarios. RESULTS: There were a total of 306 completed surveys. Residents rated their comfort level as most comfortable in scenarios regarding exhibiting empathy and least comfortable when providing bad news to patients or dealing with drug-seeking patients and difficult family members. Training was most prevalent in the areas of exhibiting empathy and giving bad news and lowest in managing drug-seeking patients and difficult patients. CONCLUSIONS: This survey revealed that Emergency Medicine residents do not consider themselves generally comfortable in multiple communication scenarios and that the amount of training received in these areas is often lacking during residency. A statistically significant positive correlation existed between comfort level and amount of graduate medical training in most areas. Results suggest that increasing the amount of communication training during residency may be of benefit in influencing how comfortably residents handle difficult patient scenarios.

Does emergency physician empathy reduce thoughts of litigation? A randomised trial.

BACKGROUND: We hypothesised the addition of brief empathetic statements to physician-patient interaction might decrease thoughts regarding litigation. METHODS: We enrolled a convenience sample of adults in our emergency department (ED) waiting room into a randomised, double-blind controlled trial. Subjects watched videos of simulated discharge conversations between physicians and patient actors; half of the videos differed only by the inclusion of two brief empathetic statements: verbalisations that (1) the physician recognises that the patient is concerned about their symptoms and (2) the patient knows their typical state of health better than a physician seeing them for the first time and did the right thing by seeking evaluation. After watching the video subjects were asked to score a five-point Likert scale their thoughts regarding suing this physician in the event of a missed outcome leading to lost work (primary outcome), and four measures of satisfaction with the physician encounter (secondary outcomes). RESULTS: We enrolled and randomised 437 subjects. 213 in the empathy group and 208 in the non-empathy group completed the trial. Sixteen subjects did not complete the trial due to computer malfunction or incomplete data sheets. Empathy group subjects reported statistically significant less thoughts of litigation than the non-empathy group (mean Likert scale 2.66 vs 2.95, difference -0.29, 95% CI -0.04 to -0.54, p=0.0176). All four secondary measures of satisfaction with the physician encounter were better in the empathy group. CONCLUSIONS: In this study, the addition of brief empathetic statements to ED discharge scenarios was associated with a statistically significant reduction in thoughts regarding litigation. CLINICAL TRIAL REGISTRATION: NCT01837706.

Posterior Scleritis with Inflammatory Retinal Detachment.

A 14-year-old African American male presented to the emergency department with worsening left eye redness, swelling, and vision loss over the preceding three days. History was notable for similar eye redness and swelling without vision loss four months earlier, which improved following a brief course of prednisone. He endorsed mild eye irritation and tearing with bright lights. There was no history of fever, respiratory symptoms or trauma. Mother was medicating patient with leftover antibiotic eye drops x3 days without improvement. Physical examination on presentation notable for proptosis of left eye, lid, and periorbital swelling, mild scleral injection, and central vision loss in affected eye (20/200 OS, 20/25 OD). Extraocular movements and pupillary exam were normal. No corneal fluorescein uptake, abnormal cell, flare, or siedel sign were seen during slit lamp exam. Eye pressures were 24 mmHg in both eyes. Bedside ultrasonography was performed (Figure 1 showing retinal detachment, Ultrasound Video 2 showing detachment in orbital scan).