Bide Your Time With Bites: A Case of Rattlesnake Envenomation in Pennsylvania.

This case report represents a 26-year-old male with no significant past medical history who presented to the emergency department in western Pennsylvania following a western diamondback rattlesnake (Crotalus Atrox) bite to his hand. His initial swelling was mild, and his coagulation studies were unremarkable, with minimal changes on repeat studies, and poison control recommended against antivenom administration. He was discharged home with oral antibiotics and analgesics due to his stable clinical course. However, he returned to the emergency department about 12 hours later with worsening pain and swelling that extended to his elbow. He was then given antivenom and transferred to a larger center for higher-level care, ultimately having symptom resolution after further antivenom administration. This report serves to underline the importance of clinician education regarding envenomation management throughout the United States, including areas without indigenous venomous snakes.

Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success.

STUDY OBJECTIVE: Prior work has found first-attempt success improves with emergency medicine (EM) postgraduate year (PGY). However, the association between PGY and laryngoscopic view - a key step in successful intubation - is unknown. We examined the relationship among PGY, laryngoscopic view (ie, Cormack-Lehane view), and first-attempt success. METHODS: We performed a retrospective analysis of the National Emergency Airway Registry, including adult intubations by EM PGY 1 to 4 resident physicians. We used inverse probability weighting with propensity scores to balance confounders. We used weighted regression and model comparison to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between PGY and Cormack-Lehane view, tested the interaction between PGY and Cormack-Lehane view on first-attempt success, and examined the effect modification of Cormack-Lehane view on the association between PGY and first-attempt success. RESULTS: After exclusions, we included 15,453 first attempts. Compared to PGY 1, the aORs for a higher Cormack-Lehane grade did not differ from PGY 2 (1.01; 95% CI 0.49 to 2.07), PGY 3 (0.92; 0.31 to 2.73), or PGY 4 (0.80; 0.31 to 2.04) groups. The interaction between PGY and Cormack-Lehane view was significant (P-interaction<0.001). In patients with Cormack-Lehane grade 3 or 4, the aORs for first-attempt success were higher for PGY 2 (1.80; 95% CI 1.17 to 2.77), PGY 3 (2.96; 1.66 to 5.27) and PGY 4 (3.10; 1.60 to 6.00) groups relative to PGY 1. CONCLUSION: Compared with PGY 1, PGY 2, 3, and 4 resident physicians obtained similar Cormack-Lehane views but had higher first-attempt success when obtaining a grade 3 or 4 view.

Reactions and needs of tristate-area pediatricians after the events of September 11th: implications for children's mental health services.

OBJECTIVE: The terrorist attacks of September 11, 2001, caused mass destruction in Lower Manhattan, the Pentagon, and rural Pennsylvania and resulted in the death of >3000 people. Children were prominent among those affected. Given the wide impact of the attacks, we hypothesized that primary care professionals would see the broad population of affected children but would feel ill-prepared to respond to children's mental health needs. METHODS: One year after the September 11th disaster, a hyperlink to a web-based 42-item survey was sent to all New York, Connecticut, and New Jersey American Academy of Pediatrics members with e-mail addresses (N = 4330), and a paper version of the survey was sent via postal mail to a random sample of those without e-mail (N = 1320). The survey requested demographic data, personal and practice experience of 9/11, perceived knowledge and skills regarding mental health, and perceived barriers to accessing mental health services for their patients. Both groups were contacted a total of 3 times at 2-week intervals, resulting in 1396 completed surveys from providers who were actively seeing patients. RESULTS: Twenty-nine percent of respondents stated that they were seeing affected patients, and 32.6% reported seeing children who were exposed to at least 1 9/11 event. Sixty-four percent of the respondents identified behavioral problems in directly affected children: 41.6% identified acute stress disorder, and 26.3% identified posttraumatic stress disorder (PTSD). However, a majority of these professionals indicated that they either lacked or were uncertain (50.8% PTSD, 51.7% acute stress disorder) of their skills to identify children with mental health problems and that they were "not" or only "somewhat" knowledgeable (76.8% PTSD) in these areas. The majority agreed that child health professionals should be trained to screen for these 2 disorders. Generalists as compared with specialists were more likely to report seeing patients who were affected by 9/11. Gender, race/ethnicity, and geographic location were associated with reported effects of 9/11 on respondents' practice and perceived skills and knowledge related to the psychological effects of community disasters. CONCLUSIONS: Pediatric practitioners in the tristate area reported that children/families sought care for an array of mental health-related concerns. Generalists in the areas affected and those who identified gaps in knowledge or skills in responding to the psychological effects of community disasters should be targeted for additional education.