Beirut Port Blast 2020: New Lessons Learned in Mass Casualty Incident Management in the Emergency Department.

BACKGROUND: On August 4, 2020, Lebanon suffered its largest mass casualty incident (MCI) to date: the Beirut Port blast. Hospital emergency response to MCIs is particularly challenging in low- and middle-income countries, where emergency medical services are not well developed and where hospitals have to rapidly scale up capacity to receive large influxes of casualties. This article describes the American University of Beirut Medical Center (AUBMC) response to the Beirut Port blast and outlines the lessons learned. DISCUSSION: The Beirut Port blast reinforced the importance of proper preparedness and flexibility in managing an MCI. Effective elements of AUBMC's MCI plan included geographic-based activation criteria, along with use of Wi-Fi messaging systems for timely notification of disaster teams. Crowd control through planned facility closures allowed medical teams to focus on patient care. Pre-identified surge areas with prepared disaster cart deployment allowed the teams to scale up quickly. Several challenges were identified related to electronic medical records (EMRs), including patient registration, staff training on EMR disaster modules, and cumbersome EMR admission process workflows. Finally, this experience highlights the importance of psychological debriefs after MCIs. CONCLUSIONS: Hospital MCI preparedness plans can integrate several strategies that are effective in quickly scaling up capacity to respond to large MCIs. These are especially necessary in countries that lack coordinated prehospital systems.

Predictors of a short hospitalization in bone marrow transplantation patients presenting to the emergency department.

BACKGROUND: Despite the advantages of bone marrow transplantation (BMT), patients receiving this intervention visit the emergency department (ED) frequently and for various reasons. Many of those ED visits result in hospitalization, and the length of stay varies. OBJECTIVES: The objective of our study was to identify the patients who were only briefly hospitalized and were thus eligible for safe discharge from the ED. METHODS: This was a retrospective cohort study conducted on all adult patients who have completed a successful BMT and had an ED visit that resulted in hospitalization. RESULTS: Our study included 115 unique BMT with a total number of 357 ED visits. Around half of those visits resulted in a short hospitalization. We found higher odds of a short hospitalization among those who have undergone autologous BMT (95%CI [1.14-2.65]). Analysis of the discharge diagnoses showed that patients with gastroenteritis were more likely to have a shorter hospitalization in comparison to those diagnosed with others (95%CI [1.10-3.81]). Furthermore, we showed that patients who presented after a month from their procedure were more likely to have a short hospitalization (95%CI [1.04-4.87]). Another significant predictor of a short of hospitalization was the absence of Graft versus Host Disease (GvHD) (95%CI [2.53-12.28]). Additionally, patients with normal and high systolic blood pressure (95%CI [2.22-6.73] and 95%CI [2.81-13.05]; respectively), normal respiratory rate (95%CI [2.79-10.17]) and temperature (95%CI [2.91-7.44]) were more likely to have a shorter hospitalization, compared to those presenting with abnormal vitals. Likewise, we proved higher odds of a short hospitalization in patients with a quick Sepsis Related Organ Failure Assessment score of 1-2 (95%CI [1.29-5.20]). Moreover, we demonstrated higher odds of a short hospitalization in patients with a normal platelet count (95%CI [1.39-3.36]) and creatinine level (95%CI [1.30-6.18]). CONCLUSION: In our study, we have shown that BMT patients visit the ED frequently and many of those visits result in a short hospitalization. Our study showed that patients presenting with fever/chills are less likely to have a short hospitalization. We also showed a significant association between a short hospitalization and BMT patients without GvHD, with normal RR, normal T °C and a normal platelet count.

Clinical characteristics and outcomes of bone marrow transplantation patients presenting to the ED of a tertiary care center.

BACKGROUND: Bone marrow transplantation is a breakthrough in the world of hematology and oncology. In our region, there is scarce literature studying emergency department visits among BMT patients, as well as their predictors of mortality. OBJECTIVES: This study aimed to assess the frequency, reasons, clinical characteristics and outcomes of patients presenting to the ED after a BMT, and to study the predictors of mortality in those patients. This study also compares those variables among the different types of BMT. METHODS: This was a retrospective cohort study conducted on all adult patients who have completed a successful BMT and visited the ED. RESULTS: Our study included 115 BMT patients, of whom 17.4% died. Those who died had a higher median number of ED visits than those who did not die. Around 36.5% presented with fever/chills with 29.6% diagnosed with pneumonia on discharge. We found that the odds of mortality were significantly higher among those who presented with dyspnea (p < .0005) and AMS (p = .023), among septic patients (p = .001), those who have undergone allogeneic BMT (p = .037), and those who were admitted to the ICU (p = .002). Moreover, the odds of mortality were significantly higher among hypotensive (p ≤0005) and tachycardic patients (p = .015). CONCLUSION: In our study, we have shown that BMT patients visit the ED very frequently and have high risk of in-hospital mortality. Moreover, our study showed a significant association between mortality and patients with dyspnea, AMS, sepsis, allogeneic BMT type, ICU admission, hypotension and tachycardia.

A Financial Plot to Reduce the Burden of Medical School Tuition Fees.

Tuition fees for medical school are continuously and riotously increasing. This upsurge is amassing debts on the backs of students. In the class of 2018, 75% finished medical school with an outstanding balance of $196,520, on average-a $5826 increase from 2017. Tuition fees differ in terms of the ownership of the medical school (public vs. private) and according to the medical student residence status (in-state or out-of-state). It is critical that students arrange a long-term budget that shows them where they stand: in surplus or in deficit. Students may classify expenditures into two groups: "fixed" and "variable," where they can manipulate the variable expenses to fit into their budget. To pay for their tuition, medical students have four possibilities: cash, scholarships and grants, service-obligation scholarships, and loans. Loans are the most common alternatives, and so there are Traditional Repayment Plans and Income-Driven Repayment Plans. This article serves to provide medical students with attainable alternatives for funding their education and for repaying their debts.

Emergency Medicine Interest Groups.

Emergency Medicine Interest Groups (EMIGs) serve as a bountiful resource for students interested in pursuing a career in Emergency Medicine (EM). In this article we elaborate on how medical students can get involved as members in an EMIG, discuss opportunities for leadership through these groups, detail how to make the most out of the EMIG (including a listing of important lectures, workshops/labs and opportunities for growth and advancement), provide a framework for how to institute a new EMIG when one does not exist, and discuss considerations for international EMIG groups.

Geriatric Mental Health and COVID-19: An Eye-Opener to the Situation of the Arab Countries in the Middle East and North Africa Region.

While the detrimental ramifications of the COVID-19 outbreak on the mental wellbeing of the general public continue to unravel, older adults seem to be at high risk. As the geriatric population continues to grow in the Middle East and North Africa (MENA) region, it is essential to explore the influence of this outbreak on geriatric mental health, a topic often neglected. In this review, we depict the status of geriatric psychiatry in the Arab countries of the MENA region, exploring the variations from one nation to another. While some have a null exposure to the field, resources and expertise in other countries range from very limited to extensive. Furthermore, we highlight the measures implemented in the Arab region to address mental health during the COVID-19 outbreak; these tend to be insufficient when targeting the geriatric population. Finally, we provide short- and long-term recommendations to stakeholders that aim at enhancing the mental healthcare of older adults in the Arab countries of the MENA region, particularly during this pandemic.

Meningitis due to Weissella Confusa.

Bacterial meningitis is a life-threatening condition that should be addressed as an emergency. The typical culprit microorganisms are targeted empirically with ceftriaxone and vancomycin, in the absence of an immunocompromised state. In this case report, however, we are describing a case of meningitis secondary to Weissella confusa, bacteria inherently resistant to the two drugs commonly used to empirically treat meningitis. Weissella spp. are Gram-positive, catalase-negative coccobacilli and an infrequent cause of infection in humans. Bacteremia followed by endocarditis are the typical clinical manifestations of W. confusa in humans. Other reported manifestations include post-operative osteomyelitis, thumb abscess, infected prosthetic joint, infected peritoneal fluid and peritonitis. To our knowledge, this is the first case of meningitis due to Weissella confusa in the literature. Therefore, we conclude that the isolation of Gram-positive coccobacilli resistant to vancomycin, especially in an immunocompromised host, should raise the suspicion of W. confusa.

The Medical School Years.

Medical school can be very challenging, especially when students are considering applying to competitive specialties, like emergency medicine. Once medical students know that emergency medicine is the field they want to specialize in, a multitude of other questions arise, including how many EM rotations should they do? How can they shine during their EM rotations? When should they schedule their rotations, electives, and sub-internships? How can they get the strongest letters of recommendation? What are residency program directors looking for? Therefore, we are going to present in the Medical Student Forum section of the Journal of Emergency Medicine a series of six articles covering this and more.

Pulmonary Embolism Can Be Nauseous: A Case Report and Review of D-Dimer Use in Pediatric Oncology Patients.

BACKGROUND: Pulmonary embolism (PE) is a very common presentation in the emergency department (ED). Despite being life-threatening, PE is preventable if diagnosed and managed early, especially in high-risk patients like pediatric oncology patients. A negative d-dimer has a high negative predictive value and can rule out PE in low-risk patients; however, it does not lower post-test probability enough and should be coupled with further diagnostics in high-risk patients. CASE REPORT: We describe the case of a 14-year-old girl known to have acute lymphoblastic leukemia and presented to the ED with persistent nausea and vomiting only, which was exacerbated by exertion. She had previously presented to the ED 1 week earlier for the same complaint, with a nonrevealing physical examination. At that time, the patient was worked up for nausea and vomiting and received symptomatic treatment. An electrocardiogram (ECG) during that presentation showed normal sinus rhythm. During this presentation, ECG showed new ST segment depressions from V1 to V6 in addition to an S1Q3T3 pattern. This, coupled with the exacerbation of her initial symptoms, triggered further investigations. Computed tomography angiography (CTA) of the chest was performed and showed a right lower lobe segmental pulmonary artery embolus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the importance of having a high level of suspicion for PE, especially in pediatric oncology patients and specifically in hematologic malignancies. Although our patient's presentation, examination, and laboratory results were not concerning initially, CTA of the chest showed a PE. We are addressing this particular topic to increase the awareness of emergency physicians of cases like this, as PE can have an unusual presentation and missing such a diagnosis can be fatal.

Designing the Third- and Fourth-Years Clerkship Schedule.

Deciding on a specialty may be one of the most daunting parts of medical school. Accordingly, it is important for medical students to make informed decisions regarding their choice of specialty. To do so, they should start planning early by contemplating possible career choices during the first 2 years of medical school, followed by properly designing their third- and fourth-year schedules. This article provides guidance and advice to medical students on how to schedule their clinical clerkships in order to optimize their ability to decide on a field of medicine to study and, ideally, to prepare them for a career in emergency medicine.

What If I Do Not Match? Scrambling for a Spot and Going Outside the Match.

Matching into emergency medicine (EM) is getting progressively more competitive. Applicants must therefore prepare for the possibility of not matching and, accordingly, be ready to participate in the Supplemental Offer and Acceptance Program (SOAP). In this article, we elaborate on the SOAP and the options for applicants who fail to match during Match Week. Alternative courses of action include applying for a preliminary year, matching into a categorical residency program, or aiming to secure EM spots outside the Match through the Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine, and American Association of Medical Colleges.

Couples Match in Emergency Medicine.

The Match is a daunting process for everyone, but it can be exceedingly more complicated for couples. Accordingly, the Couples Match was introduced by the National Residency Match Program in 1984 and has been witnessing a steady increase in the number of participating couples over the past 30 years. The highest number of couples participating in the match, and the highest match rate among them, was recorded in 2018. In this article, we provide couples considering the Couples Match, with one or both partners planning to apply to emergency medicine, with insights on this process. Although it may initially appear to be complicated, the Couples Match enables partners to obtain postgraduate training in geographic proximity to one another. With good communication between the partners and their advisors, an exciting joint venture can unfold that is fueled by the strength of the couple.

The International Medical Graduate and Emergency Medicine.

International medical graduates (IMGs) are medical graduates who have received their degree from international medical schools. IMGs must undertake a 3-step process to apply to the National Residency Matching Program match. First, they must obtain a valid standard certificate from the Educational Commission for Foreign Medical Graduates. Following certification, they must apply for and secure a position in a residency training program. Third, they must obtain a visa that would enable them to commence their training. In this article, we delve thoroughly into these stepladders to provide IMGs with a clear roadmap of the process as well as contacts to key agencies that may provide more comprehensive assistance.

Research and Scholarly Projects.

The idea of doing a research or scholarly project can be very daunting, however, the satisfaction of seeing a project to its completion is very rewarding. In this article, we provide medical students with guidance on whether they should take on a research or scholarly project during medical school, and how to get started, publish, and then present their project. We also highlight how such a project can benefit an applicant applying for residency training.

Medical Student Leadership in Emergency Medicine.

Emergency medicine is a profession that requires good leadership skills. Emergency physicians must be able to instill confidence in both the staff and patients, inspire the best in others, have the enthusiasm to take on a surplus of responsibilities, and maintain calmness during unexpected circumstances. Accordingly, residency program directors look carefully for leadership qualities and potential among their applicants. Although some people do have a predisposition to lead, leadership can be both learned and taught. In this article, we provide medical students with the tools that will help them acquire those qualities and thus make them more desirable by program directors.

Clerkships in Emergency Medicine.

Planning for clerkships in emergency medicine (EM) can be stressful, prolonged, and challenging. Therefore, medical students should start planning for them early. In this article, we offer guidance regarding several issues pertinent to the EM clerkship, such as the best time to schedule one (or more) during medical school, the most appropriate institution or program to schedule it, the process of selecting and applying for the clerkship, and the number of EM clerkships to consider. We will explain why an EM clerkship should be scheduled between June and October and the reason that 2 EM clerkships at different sites are sufficient for the majority of students. Additionally, we emphasize that clerkships in emergency departments associated with EM residency programs or with reputations for outstanding student teaching tend to be most beneficial. Above all, students interested in EM should attempt to leave a great impression after completing their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and maintaining professionalism. In turn, they will gain knowledge and clinical experiences that should prove valuable in their future.

Uniformed Medical Students and Residents in Emergency Medicine.

"Uniformed medical students and residents" refers to medical school enrollees and physicians in training who are obligated to serve in the military after graduation or training completion. This is in exchange for 2 forms of financial support that are provided by the military for individuals interested in pursuing a career in medicine. These programs are offered namely through the Uniformed Services University of Health Sciences (USUHS) and the Health Professions Scholarship Program (HPSP). Uniformed medical school graduates can choose to serve with the military upon graduation or to pursue residency training. Residency can be completed at in-service programs at military treatment facilities, at out-service programs, at civilian residency training programs, or via deferment programs for residency training at civilian programs. Once their residency training is completed, military physicians should then complete their service obligation. As such, both USUHS and HPSP students should attend a basic officer training to ensure their preparedness for military service. In this article, we elaborate more on the mission, requirements, application, and benefits of both USUHS and HPSP. Moreover, we expand on the officer preparedness training, postgraduate education in the military, unique opportunities of military medicine, and life after completion of military obligation.

An Introduction to the Residency Application Process.

Emergency medicine (EM) is a swiftly developing yet still relatively young discipline. We are going to present in the Medical Student Forum section of the Journal of Emergency Medicine several article series covering the key topics that medical students interested in emergency medicine will find helpful. This article introduces the topics that will be tackled in the first compilation of articles dealing with the residency application process.

The Osteopathic Applicant.

The number of osteopathic students choosing emergency medicine (EM) as a specialty is continuously increasing. However, EM remains a competitive specialty. Accordingly, in this article we guide osteopathic students interested in EM through the Comprehensive Osteopathic Medical Licensing Examination (COMLEX), the United States Medical Licensing Examination (USMLE), third- and fourth-year rotations, and the match process. Additionally, we provide tips on the process of applying to allopathic programs and we discuss the timeline of both the allopathic and osteopathic match. Finally, we discuss the effect of the Single Accreditation System and the Memorandum of Understanding, an agreement to merge the allopathic and osteopathic graduate medical education systems into a single graduate medical education accreditation system. This is expected to be completed as of July 1, 2020. Therefore, we elucidate the expectations for osteopathic applicants (particularly with regards to the USMLE and COMLEX examinations).

Three- vs. Four-Year Emergency Medicine Training Programs.

Postgraduate training in emergency medicine (EM) varies in length among different programs. This fact creates a dilemma for applicants to the specialty of EM and prevents EM educators from reaching a consensus regarding the optimal length of training. Historically, EM training existed in the postgraduate year (PGY) 1-3, 2-4, and 1-4 formats, until the PGY 2-4 program became obsolete in 2011-2012. Currently, three-quarters of EM programs follow the PGY 1-3 format. In this article, we clarify for the applicants the main differences between the PGY 1-3 and PGY 1-4 formats. We also discuss the institutional, personal, and graduate considerations that explain why an institution or an individual would choose one format over the other.