Ketamine's love story with the heart: A Takotsubo twist.

INTRODUCTION: Ketamine is a dissociative anesthetic with N-methyl-d-aspartate and glutamate receptor antagonist properties. It has been the most popular agent to facilitate emergency department procedures for three decades. Considered a safe and effective option for procedural sedation, ketamine has rapid onset, short effective sedation time, and a low risk profile. Ketamine's sympathomimetic effects could theoretically induce stress-related cardiac dysfunction, including cardiomyopathy. A review of the literature demonstrates one prior report of stress (Takotsubo) cardiomyopathy after ketamine sedation. CASE REPORT: In this case report, we present a case of Takotsubo cardiomyopathy after ketamine sedation for distal radius fracture reduction. The patient presented hemodynamically normal with an unremarkable cardiac ultrasound and progressed to hypoxia from bilateral pulmonary edema, eventually requiring intubation. Inpatient evaluation revealed elevated high sensitivity troponin, non-obstructive coronary arteries on catheterization, and echocardiogram findings of Takotsubo cardiomyopathy. She received operative fixation of her radius fracture by orthopedics and was discharged home on hospital day 9. She had an unremarkable follow up with cardiology but had no echocardiogram to determine full resolution. CONCLUSION: Although ketamine has robust evidence of safety and efficacy, physicians should be aware of the potential complications of its sympathomimetic effects, from hypertension and tachycardia to overt Takotsubo cardiomyopathy.

Carbon Monoxide Levels Produced by Propane/Isobutane Canister Stoves inside a Tent.

INTRODUCTION: Improper use of camp stoves in enclosed spaces has resulted in fatalities from carbon monoxide (CO) poisoning. Prior research has focused on the CO output of stoves burning white gas, unleaded gas, or kerosene. Stoves burning an isobutane/propane fuel have not been investigated and are the focus of this study. METHODS: Three stoves utilizing isobutane/propane fuel were used to heat a pot of water inside a 3-season tent under controlled settings. Multiple runs with each stove were performed, and CO measurements, in parts per million (ppm), were recorded at 1-min intervals for a total of 15 min using a RAE Systems gas monitor. Data are reported as mean with SD. Repeated measures analysis of variance was utilized to examine changes over time. Statistical significance was set at P<0.05. RESULTS: There was a statistically significant main effect of time and CO level, F (14, 168)=7.6, P<0.001. There was a statistically significant difference between-subjects effect of stove group F (2, 12)=8.6, P=0.005, indicating that CO levels were different depending on the stove. Tukey's post-hoc analyses revealed that stove A had the highest CO levels. The average level of stove A was statistically significantly higher than that of stove B and stove C, with a mean CO level difference of 79 ppm (95% CI, 3-156), P=0.043 and 117 ppm (95% CI, 40-194), P=0.004, respectively. CONCLUSIONS: Stoves utilizing isobutane/propane fuel can produce unsafe CO levels and should not be used in enclosed spaces.

An analysis of statistical terminology applied in emergency medicine literature methods.

INTRODUCTION: Given the importance of understanding methodical reporting and statistical terminology in ensuring evidence-based decision-making, physicians should possess statistical literacy. The purpose of this study was to distinguish statistical terminology commonly used in emergency medicine methods and describe changes in statistical methods from 2011 to 2021. METHODS: The research team chose four journals in emergency medicine widely read and clinically relevant: Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Medicine. A total of 400 research articles were included. The team compared overall frequencies in statistical word counts as well as differences by year (2021 vs 2011). RESULTS: Included words from 2011 totaled 31,002 compared to 38,272 in 2021. Unique words for 2011 included 3801 compared to 4291 in 2021. The most common statistical words found in both years were model(s), difference(s), and regression(s). The largest increases in usage included the following words: noninferior(ity), NPV, Fixed, AUC, Mixed, Shapiro, and Wilk. Compared to 2011, results showed a 10% decrease in "p" for 2021. While the terms "Confidence" (2%) and "Intervals" (6%) decreased from 2011 to 2021, there was a 25% increase in "CI(s)". CONCLUSION: By understanding common statistical terms and trends over time, educational efforts can be targeted to consumers of EM literature. Additionally, this work provides evidence suggesting an overall improvement in processes in statistical methodology, enhancing the quality of research outputs and ultimately allowing better clinical decision-making.

Equal incidence of COVID-19 among homeless and non-homeless ED patients when controlling for confounders.

INTRODUCTION: The World Health Organization (WHO) declared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a pandemic in March 2020. Theoretically, homeless patients could have disproportionately worse outcomes from COVID-19, but little research has corroborated this claim. This study aimed to examine the demographics and incidence of COVID-19 in homeless vs non-homeless emergency department (ED) patients. METHODS: This is a retrospective study of all patients seen in the University of Louisville Hospital Emergency Department (ULH ED) from March 2019 to December 2020, excluding January and February 2020. Data was collected from the Kentucky Homeless Management Information System (HMIS) and ULH electronic health records. RESULTS: A total of 51,532 unique patients had 87,869 visits during the study period. There was a 18.1% decrease in homeless patient visits over the time period, which was similar to the decrease in non-homeless patient visits (19.2%). In the total population, 9471 individuals had known COVID-19 testing results, with a total of 610 positive (6.4% positivity rate). Of the 712 homeless ED patients, 39 tested positive (5.5% positivity rate). After adjusting for age, gender identity, race, and insurance, there was no statistically significant difference in test positivity between homeless and non-homeless patients, OR 1.23 (0.88, 1.73). Homeless patients were less likely to be admitted to either the intensive care unit (ICU) or hospital (OR = 0.55, 95% CI: OR 0.51, 0.60) as they were more likely to be discharged (OR = 1.65, 95% CI: 1.52, 1.79). CONCLUSION: Previous literature has indicated that higher disease burden, lack of access to social distancing, and poor hygiene would increase the risk of homeless individuals contracting COVID-19 and experiencing serious morbidity. However, this study found that homelessness was not an independent risk factor for COVID-19 infection.

Prospective study of haloperidol plus lorazepam versus droperidol plus midazolam for the treatment of acute agitation in the emergency department.

STUDY OBJECTIVES: The objective of this study was to compare the combination of intramuscular (IM) droperidol/midazolam to haloperidol/lorazepam regarding time to sedation in patients with acute undifferentiated agitation in the emergency department (ED). METHODS: This was a prospective, unblinded observational study in the ED of a university teaching hospital. Subjects with acute undifferentiated agitation refractory to verbal de-escalation were assigned to receive a combination of either haloperidol 5 mg/lorazepam 2 mg or droperidol 5 mg/midazolam 5 mg IM. The primary outcome was the proportion of patients adequately sedated at 10 min defined as ED Sedation Assessment Tool (SAT) score of 0 or less. Secondary outcomes included change in ED SAT score at 5, 15, 30, and 60 min, the need for oxygen supplementation, and the need for airway intervention. RESULTS: A total of 86 patients were enrolled in the study, with 43 patients receiving droperidol/midazolam and 43 patients receiving haloperidol/lorazepam. Ten minutes after receiving medication, 51.2% of patients in the droperidol/midazolam group were adequately sedated compared to 7% of patients in the haloperidol/lorazepam group (OR: 14; 95% CI: 3.7, 52.1). Median time to adequate sedation was 10 min for the droperidol/midazolam group and 30 min for the haloperidol/lorazepam group. Eleven patients (25.6%) in the droperidol/midazolam group received oxygen supplementation compared to four patients (9.3%) in the haloperidol/lorazepam group. No study patients experienced extrapyramidal symptoms or required endotracheal intubation. CONCLUSION: Intramuscular droperidol/midazolam was superior to intramuscular haloperidol/lorazepam in achieving adequate sedation at 10 min. Patients in the droperidol/midazolam arm may be more likely to receive oxygen supplementation than those in the haloperidol/lorazepam arm.

Planning virtual residency interviews as a result of COVID-19: insight from residency applicants and physicians conducting interviews.

BACKGROUND: In response to the COVID-19 pandemic, the 2020-2021 residency interview process will undergo significant changes. Residency programme stakeholders would benefit from knowledge on what students and physicians expect from this process. OBJECTIVE: The purpose of the study was to describe and contrast the perspectives of student applicants and interviewing physicians related to the residency programme virtual interview process. METHODS: A survey consisting of 24 Likert statements was administered across listservs in summer 2020 to physicians (attendings and residents who interview medical students). Medical students also received an anonymous survey and were recruited via email to participate. RESULTS: A total of 155 individuals (104 fourth-year medical students and 51 physicians) completed a survey. Results showed students would prefer in-person interviews over virtual. Residency applicants had high agreement on the limited ability to fully assess the programme and city due to virtual interviews. Individuals with lower step 1 scores had higher agreement on preferring in-person interviews. Individuals in the lowest and highest scoring groups appear more worried about the representation of themselves as a result of virtual interviews. Furthermore, applicants feel that more weight will be placed on steps 1 and 2 scores and class ranks, and they may not be able to fully demonstrate their personality compared with interviewers. CONCLUSION: The result of COVID-19 has created challenges and subsequent reshuffling of medical education requiring careful preparation and planning. This study provides insight for residency programmes to better understand the applicants' expectations for the 2020-2021 residency interview and matching process.

Brief Report: The Impact of COVID-19 on Emergency Department Overdose Diagnoses and County Overdose Deaths.

BACKGROUND AND OBJECTIVES: We sought to understand the impact of COVID-19 on emergency department (ED) overdoses and county coroner verified overdose deaths. METHODS: Electronic medical health record and county coroner data were gathered and comparisons were made between three 16-week time periods. In the three time periods, 873 individuals had an overdose diagnosis in the ED and 440 individuals in the county died of drug overdose. RESULTS: While total ED patient volume decreased substantially, the number of ED overdose patients increased between March 6 and June 25, 2020. Furthermore, during this same period, coroner data revealed an increase in overdose deaths. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This preliminary evidence provides a key insight into the impact of COVID-19 on both overdose presentations to the ED and county overdose deaths. These results emphasize the critical need for increasing vigilance to prevent overdose by continuously developing and optimizing both accessible and quality treatment as we navigate through this pandemic and its ongoing effects on persons with substance use disorder. (Am J Addict 2021;00:00-00).

COVID-19 and emergency department volume: The patients return but have different characteristics.

BACKGROUND: The COVID-19 pandemic has altered behaviors in the general population, as well as processes in the healthcare industry. Patients may be afraid to pursue care in the emergency department (ED) due to perceived risk of infection. The objective of this study was to determine the impact of COVID-19 on ED metrics. METHODS: At one metropolitan trauma center ED, we conducted a review of all visits from February to May in 2020 and compared findings with the same months from 2019. RESULTS: A total of 34,213 ED visits occurred during the study periods (18,471 in 2019 and 15,742 in 2020), with a decline in patient visits occurring after state emergency declarations. In 2020, patients were less likely to be female and more likely to arrive by ambulance. Diagnoses in the musculoskeletal, neurologic, and genitourinary categories occurred in lower proportions in 2020; toxicology, psychiatry, and infectious diseases occurred in higher proportions. In contrast to other insurance categories, Medicare patients comprised a larger share of ED visits in 2020 compared to 2019. DISCUSSION: Despite relatively low local prevalence of COVID-19, we report decreases in ED volume for some medical diagnosis categories. A volume rebound occurred in May 2020, but did not reach 2019 levels. Public health officials should encourage local populations to seek emergency care when concerned, and could consider programs to provide transportation. Patients should continue to protect themselves with social distancing and masks.

Association between Characteristics of Impostor Phenomenon in Medical Students and Step 1 Performance.

THEORY: Impostor phenomenon (IP) is a widely recognized experience in which highly performing individuals do not internalize success. Self-doubt toward one's ability or intelligence is unexpectedly common. Prior research has associated IP with medical student perceptions, burnout, and demographic characteristics. However, understanding how student IP experiences are related to actual academic achievement could help medical schools better support student performance and resilience. Hypotheses: The purpose of this research was to examine whether there is a relationship between medical students' USMLE Step 1 scores and experiences of IP. Because medical students receive frequent, objective feedback on exam performance, we hypothesized that students with lower Step 1 scores would experience higher levels of IP. Methods: In 2019, all M1-M4 students at the University of Louisville were invited to complete Clance's (1985) Impostor Phenomenon Scale (CIPS), a previously validated, 20-item, Likert-style scoring instrument designed to reflect respondents' IP experience. We categorized subjects into one of four levels based on CIPS scoring guidelines. For students who had completed Step 1 at the time of the survey, we conducted a Welch's ANOVA test to identify relationships between a student's level of experienced IP and Step 1 scores. We also completed an item analysis comparing individual CIPS item responses with Step 1 performance. Results: Per the CIPS scoring guidelines, we categorized the 233 respondents as experiencing few (10.3%), moderate (47.6%), frequent (31.8%), or intense (10.3%) characteristics of IP. Nearly 90% of our sample experienced at least moderate levels of IP, with over 40% experiencing frequent or intense IP. There were no statistically significant differences among CIPS groups and mean Step 1 scores [F (3, 59.8) = 1.81, p = 0.155], and total/inter-quartile Step 1 score ranges broadly overlapped among all four IP experience levels. Within-item response patterns among high and low-scoring students also varied across individual CIPS items. Conclusions: The association between IP experience and Step 1 performance was nonlinear in our cross-sectional sample: the group having the most intense IP experiences did not have the lowest score rank on Step 1, nor did the group with the fewest IP characteristics make up our highest performing group. This, along with the broad dispersion of scores within each of the four IP levels, suggests that students' internalization of achievement and feelings of IP are not consistently aligned with their actual performance on this assessment. Response variation on individual CIPS items suggest that underlying factors may drive variation in IP and performance. These results highlight the need for additional work to identify the constructs of IP that influence medical students specifically so that medical education stakeholders may better understand IP's impact on other facets of medical school and implement the resources necessary to support individuals who experience IP.

A Global Pandemic and Substance Use Disorder: Healthcare Professionals' Viewpoints on the Merging of Two Crises.

INTRODUCTION: COVID-19 has resulted in extraordinary adversities. Mandates such as distancing and variations to treatment services were implemented to slow transmission of the virus, but created new challenges for persons with Substance Use Disorder (SUD). To better understand this phenomenon, we surveyed healthcare professionals on how they believe COVID-19 has impacted persons with SUD and what needs to occur to effectively treat this vulnerable population. Methods: Attending physicians, residents, nurses, medical and nursing students, and other healthcare professionals were asked to respond to three open-ended questions related to the impact of COVID-19 on persons with SUD. Two independent coders reviewed the comments utilizing constant comparative analysis to develop themes. Results: Common themes of concern were found from the respective participants (n = 205) including: lack of access to treatment, feelings of isolation, negative impacts on mental health, and the possibility of relapse. Healthcare strategies to effectively treat and help persons with SUD included increasing access to treatment including telehealth, development of peer support groups, availability of mental health resources, development of enhanced communication channels between providers and patients, and systematic changes. Conclusion: During the COVID-19 pandemic, overdose deaths have dramatically increased. As the short-term and long-term effects of the pandemic become more apparent, swift and comprehensive responses and policies must be enacted. This study provides insight from healthcare providers on the effects of the pandemic for persons with SUD. Many preexisting issues remain unresolved (e.g. stigma and healthcare disparities), and now the pandemic has presented new obstacles as noted by the providers. The findings from this study provide implications for important discussion regarding the development of strategies for substance use treatment and harm reduction.

Perceptions diverge on aspects related to substance use disorder: An analysis of individuals in recovery, physicians, nurses, and medical students.

Background: Interactions with healthcare workers can provide effective entrance into treatment, ensuring retention and lifelong recovery for individuals with Substance Use Disorder (SUD). Healthcare providers approach the challenges of patient management with different skills, comfort levels, and viewpoints. Individuals in recovery also provide crucial perspectives relevant to the complex aspects of the drug epidemic. The purpose of this study was to determine if perceptions of SUD diverge among individuals in recovery, physicians, nurses and medical students. Methods: A survey consisting of 29 Likert statements was deployed to physicians, nurses, medical students, and persons with SUD in recovery. Respondents were asked to rate their level of agreement on statements about SUD such as treatment, stigma, medications for opioid use disorder (MOUD), naloxone kits, safe injection sites, and methamphetamine usage. Separate Welch's analysis of variances (ANOVAs) were conducted to determine differences between the respondent groups and each statement. For any statistically significant findings, Games-Howell post-hoc analyses were employed. Results: A total of 523 individuals provided survey responses: individuals in recovery (n = 111), physicians (n = 113), nurses (n = 206), and medical students (n = 93). Survey results revealed the majority of items had statistically significant differences in respondent groups. Perceptions diverged on items related to treatment, stigma, MOUD, take-home naloxone kits, safe injection sites, needle exchange programs, and methamphetamine. Conclusion: As healthcare providers and policymakers develop treatment strategies to engage those with SUD in quality treatment, they will benefit from understanding how different viewpoints on SUD affect treatment for these individuals. These attitudes impact stigma, willingness to prescribe new treatments, and development of clinical relationships. The insight from this study allows for important discussions on the substance use health crisis and further inquiry on why these differences exist and how the diverging viewpoints may impact the lives of persons with SUD.

Prescription History Before Opioid Overdose Death: PDMP Data and Responsible Prescribing.

INTRODUCTION: As the opioid epidemic continues, state legislatures and clinicians increasingly utilize Prescription Drug Monitoring Programs (PDMPs). These programs record dates prescribed and filled for all controlled substances, attempting to identify high-risk prescribing. The aims of this study were to (i) examine data from individuals who died of accidental opioid overdose and (ii) compare differences between those with prescriptions documented in Kentucky's PDMP with individuals without recorded prescriptions. METHODS: This was a retrospective, observational cohort study conducted in Jefferson County, Kentucky. We reviewed records for all opioid overdose death subjects from 2017 and 2018, cross-referencing with prescriptions in Kentucky's PDMP (Kentucky All Schedule Prescription Electronic Reporting System [KASPER]) back to 2014. We performed χ2 analyses for categorical variable comparisons and a separate univariate analysis for age. RESULTS: Of the 575 individuals who died of accidental opioid overdose in Jefferson County during the study period, 379 (65.9%) had prescriptions documented in KASPER. Individuals had a high prevalence of fentanyl on postmortem toxicology. Only one individual had postmortem toxicology positive for buprenorphine, a medication for opioid use disorder (MOUD). Several subjects experienced what we termed see-saw MOUD prescribing (prescriptions alternating between MOUD and other controlled substances including full agonists), and multiple prescriptions were apparently written and/or filled for deceased subjects. CONCLUSIONS: Review of PDMP data in deceased patients can prevent unnecessary opioid prescribing and optimize clinical practice. Buprenorphine may have a protective effect in opioid dependence, but access must be consistent. Providers should be aware of see-saw MOUD prescribing and understand the effects on patient care. In response to the prescriptions filled for deceased individuals, legislators could enact a policy such as Void All Prescriptions or VAP alerts to cancel all prescriptions for individuals who have died, reducing drug diversion. It is vital that providers routinely use PDMP data along with counseling and other treatment strategies to optimize patient care.

Snakebites Reported to the Kentucky Regional Poison Control Centers for the Years 2012-2016.

INTRODUCTION: Snake envenomations cause significant morbidity and mortality. The goals of this study were to assess the epidemiology of snakebites in Kentucky and treatment strategies used by physicians reporting to the Kentucky Regional Poison Control Centers. METHODS: This was a descriptive epidemiologic study compiling clinical data on snakebites reported to the Kentucky Regional Poison Control Centers from 2012 to 2016. We built a database of the patient demographics, treatment, and clinical course of each snakebite reported in the study period. Attention was paid to all antivenom interventions and use of contraindicated therapies. RESULTS: We compiled 674 total records. Patient age was 34±18 y (mean±SD), with males (71%) predominating. Most (97%) bites were to a distal upper or lower extremity. The majority (78%) occurred at a private residence. Most reports came between May and September (88%). Of the 674 patients, 24% (n=159) were classified as moderate or severe. Two hundred thirty (34%) patients were admitted to the hospital. Forty-six patients (7%) received surgical consultation, and 12 (2%) underwent surgical intervention. One hundred fifty-three patients received antivenom, with 6±3 vials used per patient. Length of stay was 3±2 d when antivenom was administered and 2±2 d when not administered. Six cases of coagulopathy were noted. Multiple contraindicated therapies were noted. CONCLUSIONS: Snake envenomations are a prevalent public health concern for residents of Kentucky, chiefly during summer months. Significant medical intervention is being performed for many patients, with a high prevalence of contraindicated therapies. More data are needed to fully characterize the epidemiologic impact and appropriateness of the interventions being applied.

Opioid Overdoses for Recently Incarcerated Individuals: Toxicology Results and Risk Evaluations.

Background: The opioid epidemic continues to challenge the United States, fueled by illicitly manufactured fentanyl. All stakeholders involved in fighting the opioid epidemic, from medical providers to policy makers, will benefit from understanding what contributes to overdoses. Recently incarcerated individuals represent a particularly vulnerable population. Methods: We performed a retrospective review of Jefferson County Coroner data for overdose deaths by postmortem toxicology between January 2017 and December 2018. Patients were cross-referenced with Jefferson County Department of Corrections (DOC) records, with inclusion of individuals with violations after January 2016 to focus on recently incarcerated individuals. We analyzed substances found in toxicology reports and substance risk level assigned based on screening by the DOC. Results: A total of 575 opioid overdose deaths occurred in Jefferson County from 2017-2018, with 55 of these individuals having interaction with the DOC after January 1, 2016. DOC population individuals had statistically significant higher findings of amphetamines/methamphetamines. Individuals from the DOC population had higher frequencies of fentanyl, heroin, cocaine, and cannabinoid/THC; however, these differences were not statistically significant. Prisoners with substance risk assessment scores of high or very high had fewer days from release to overdose death. Conclusion: Fentanyl remains a major contributor to overdose death, including those recently incarcerated. Substance risk assessment tools should drive referral for treatment while in prison and at time of release. These results provide better insight into the opioid epidemic and may help guide medical care, specifically for recently incarcerated individuals.

Patients with Abrasion or Ecchymosis Seat Belt Sign Have High Risk for Abdominal Injury, but Initial Computed Tomography is 100% Sensitive.

BACKGROUND: Trauma providers seek to accurately assess the risk of patients with abdominal seat belt sign (ASBS). As hospital costs continue to rise, identification of strategies to safely discharge emergency department (ED) patients has become crucial. OBJECTIVES: The purpose of this study is to 1) describe a large cohort of patients by type of ASBS and 2) determine the value of computed tomography (CT) of the abdomen and pelvis as a screening tool to rule out intra-abdominal injury (IAI) and support discharge of stable patients. METHODS: We conducted a retrospective case series of all patients presenting to our urban, Level I trauma center from 2013-2015. We studied motor vehicle collision patients who presented with ASBS. We further classified individuals into ASBS groups: Abrasion, Ecchymosis, Abrasion + Ecchymosis, or Unknown ASBS to examine differences between groups. RESULTS: In one of the largest described cohorts, the ASBS remained associated with IAI, most commonly, solid organ injury. Of 425 patients, 36.1% had some IAI on CT, but only 13.6% required laparotomy. Categorizing the type of skin injury in ASBS, we found that both abrasion and ecchymosis were associated with IAI. Initial CT performed with 100% sensitivity. CONCLUSIONS: This study shows that ED trauma patients with significant seat belt abrasion or contusion can have IAI. With the very high sensitivity of modern abdominal CT scanners, clinicians could consider safe ED discharge of stable ASBS patients while providing strong return precautions. Our large cohort strengthens the evidence on decision-making in ASBS patients to ensure outcomes and use of health care resources.

Testing Alertness of Emergency Physicians: A Novel Quantitative Measure of Alertness and Implications for Worker and Patient Care.

BACKGROUND: Establishing practical solutions to manage fatigue in health care settings could reduce errors. Predictive Safety SRP Inc.'s AlertMeter is a 2-min cognitive assessment tool currently used in high-hazard industries to identify fatigued staff. OBJECTIVE: No prior study has attempted to address fatigue in emergency medicine (EM). We objectively assessed provider alertness to determine potential application of software-based fatigue recognition for risk reduction. METHODS: In a double-blind, prospective evaluation from July 1 to September 30, 2016, we applied the AlertMeter to EM residents at an academic level I trauma center. The tool was applied before and after shifts to evaluate alertness in three types of shifts: day, evening, and night. All residents were invited to participate-27 of 30 enrolled. Analysis of covariance (ANCOVA) was implemented to examine shift and completion effects on alertness score using baseline score as a covariate. Additionally, three separate ANCOVAs were conducted to examine alertness score differences between portion (start vs. end) and type of shift (day, evening, or night). RESULTS: Residents were significantly less alert at the completion of the evening shift. Scores at the end of the night shift were significantly lower than the start of the night shift. CONCLUSIONS: Alertness software can be reliably integrated into the emergency department. Alertness was lower at the end of the evening shift and end of the night shift. This work could have positive implications on shift and task scheduling and potentially reduce errors in patient care by quantifying providers' fatigue and identifying areas for countermeasures.

Retrospective Review of Need for Delayed Naloxone or Oxygen in Emergency Department Patients Receiving Naloxone for Heroin Reversal.

BACKGROUND: Emergency departments (EDs) are experiencing an increasing number of heroin overdose visits. Currently, there is no generally agreed upon ED observation period for heroin overdose patients who receive naloxone. OBJECTIVES: We aimed to determine the safety of a 2-h observation period for heroin overdose patients who receive naloxone. METHODS: We performed a chart review of all patients who presented with any opioid-related complaint between 2009 and 2014 to our urban academic trauma center. Subset analysis of patients with isolated heroin overdose who received naloxone was performed, with the intent of excluding patients intoxicated with long-acting/enteral opioids. The primary outcome was the number of patients who required delayed intervention-specifically, additional naloxone or supplemental oxygen. RESULTS: Between 2009 and 2014, we recorded 806 visits to our ED for heroin use after receiving naloxone. Twenty-nine patients (3.6%) received a repeat dose of naloxone, and 17 patients (2%) received oxygen ≥2 h after initial naloxone administration. Our 2-h intervention rate was 4.6% (N = 37). This decreased to 1.9% (N = 15) after 3 h and 0.9% (N = 7) after 4 h. Patients with polysubstance use were more likely to receive repeat naloxone (p < 0.01), but not oxygen (p = 0.10). Preexisting cardiopulmonary conditions did not correlate with a need for supplemental oxygen (p = 0.24) or repeat naloxone (p = 0.30). CONCLUSIONS: A 2-h ED observation period for heroin overdose patients reversed with naloxone resulted in a delayed intervention rate of 5%. Clinicians may consider a 3-h observation period, with extra scrutiny in polysubstance abuse.

Does My Emergency Department Doctor Sleep? The Trouble With Recovery From Night Shift.

BACKGROUND: Previous research has shown that emergency physicians have an increased risk of shift work sleep disorder, potentially compromising their health, wellness, and effectiveness as a physician. OBJECTIVES: This study explores the effect of shift work on sleep in emergency doctors. The hypothesis of the evaluation is that daytime sleep onset would lead to the poorest sleep, implying poor recovery after a night shift. METHODS: Sleep patterns were examined in emergency physicians in an academic emergency department. Twenty-seven individuals completed data collection, wearing wrist actigraphy devices over 3 months. Time of sleep onset was categorized as falling into 1 of 3 ranges: interval 1-day sleepers (6:00 am-2:00 pm), interval 2-evening sleepers (2:00 pm-10:00 pm), or interval 3-night sleepers (10:00 pm-6:00 am). Data from each interval were analyzed for median duration, sleep latency, and night-time interruptions. RESULTS: Daytime sleep sessions had a median total sleep duration of 5.3 ± 2 h, much less than 7.3 ± 1.8 h (interval 2-evening), and 7.0 ± 1.1 h (interval 3-night). Interval 2 sleepers experienced the highest number of nightly awakenings (1.5) and the longest sleep latency (36.5 min). Day sleepers (interval 1), assumed to be predominantly physicians recovering from night shifts, had significantly less sleep than both evening and night sleepers (p < 0.01), experiencing a 23.0% decrease in overall median sleep duration. CONCLUSIONS: This study provides statistical findings that those working the night shift experience significantly less sleep than emergency physicians working other shifts.

Prevalence of Emergency Department Patients Presenting with Heroin or Prescription Opioid Abuse Residing in Urban, Suburban, and Rural Jefferson County.

BACKGROUND: Heroin and prescription opioid abuse in the United States is exhibiting a growing geographic ubiquity. OBJECTIVES: This study characterizes the changing geographic distribution of patients presenting with heroin and prescription opioid abuse to one urban emergency department (ED). METHODS: A retrospective review of patients with heroin and prescription opioid abuse from 2009-2014 was conducted in one adult urban ED. The primary outcome was the prevalence of heroin and prescription opioid patients residing in urban, suburban, and rural ZIP codes over time. RESULTS: From 2009 to 2014, 2695 patients presented for either heroin (N = 1436; 53%) or prescription opioid (N = 1259; 47%) abuse from 32 Jefferson County ZIP codes. Of the 32 ZIP codes, 15 were urban (47%), 13 suburban (41%), and 4 rural (12%). The prevalence of heroin patients (per 10,000 population) increased in each ZIP code from 2009-2014. After 2011, prescription opioid prevalence decreased in urban and suburban ZIP codes but increased in rural ones. Using segmented regression analysis, the increase in patients who used heroin residing in all ZIP codes and the decrease in patients abusing prescription opioids residing in urban areas was statistically significant after 2011. CONCLUSION: From 2009 to 2014, there was an increasing trend in ED patients using heroin who resided in urban, suburban, and rural ZIP codes. There was an increasing trend in prescription opioid prevalence in all regions from 2009 to 2011. After 2011, prescription opioid prevalence decreased in urban and suburban ZIP codes but not rural ZIP codes.

Malpractice in Emergency Medicine-A Review of Risk and Mitigation Practices for the Emergency Medicine Provider.

BACKGROUND: Malpractice in emergency medicine is of high concern for medical providers, the fear of which continues to drive decision-making. The body of evidence evaluating risk specific to emergency physicians is disjointed, and thus it remains difficult to derive cohesive themes and strategies for risk minimization. OBJECTIVE: This review evaluates the state of malpractice in emergency medicine and summarizes a concise approach for the emergency physician to minimize risk. DISCUSSION: The environment of the emergency department (ED) represents moderate overall malpractice risk and yields a heavy burden in finance and time. Key areas of relatively high litigation occurrence include missed acute myocardial infarction, missed fractures/foreign bodies, abdominal pain/appendicitis, wounds, intracranial bleeding, aortic aneurysm, and pediatric meningitis. Mitigation of risk is best accomplished through constructive communication, intelligent documentation, utilization of clinical practice guidelines and generalizable diagnoses, careful management of discharge against medical advice, and establishing follow-up for diagnostic studies ordered while in the ED (especially x-ray studies). Communication breakdown seems to be more predictive of malpractice litigation than injury experienced. CONCLUSIONS: There are consistent diagnoses that are associated with increased litigation incidence. A combination of mitigation approaches may assist providers in mitigation of malpractice risk.