Assessing Acid-Base Status in Circulatory Failure: Relationship Between Arterial and Peripheral Venous Blood Gas Measurements in Hypovolemic Shock.

BACKGROUND AND OBJECTIVES: In severe circulatory failure agreement between arterial and mixed venous or central venous values is poor; venous values are more reflective of tissue acid-base imbalance. No prior study has examined the relationship between peripheral venous blood gas (VBG) values and arterial blood gas (ABG) values in hemodynamic compromise. The objective of this study was to examine the correlation between hemodynamic parameters, specifically systolic blood pressure (SBP) and the arterial-peripheral venous (A-PV) difference for all commonly used acid-base parameters (pH, Pco 2, and bicarbonate). DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Data were obtained prospectively from adult patients with trauma. When an ABG was obtained for clinical purposes, a VBG was drawn as soon as possible. Patients were excluded if the ABG and VBG were drawn >10 minutes apart. RESULTS: The correlations between A-PV pH, A-PV Pco 2, and A-PV bicarbonate and SBP were not statistically significant (P = .55, .17, and .09, respectively). Although patients with hypotension had a lower mean arterial and peripheral venous pH and bicarbonate compared to hemodynamically stable patients, mean A-PV differences for pH and Pco 2 were not statistically different (P = .24 and .16, respectively) between hypotensive and normotensive groups. CONCLUSIONS: In hypovolemic shock, the peripheral VBG does not demonstrate a higher CO2 concentration and lower pH compared to arterial blood. Therefore, the peripheral VBG is not a surrogate for the tissue acid-base status in hypovolemic shock, likely due to peripheral vasoconstriction and central shunting of blood to essential organs. This contrasts with the selective venous respiratory acidosis previously demonstrated in central venous and mixed venous measurements in circulatory failure, which is more reflective of acid-base imbalance at the tissue level than arterial blood. Further work needs to be done to better define the relationship between ABG and both central and peripheral VBG values in various types of shock.

Are awe-prone people more curious? The relationship between dispositional awe, curiosity, and academic outcomes.

OBJECTIVE: Guided by a functional account of awe, we aimed to test the hypothesis that people who often feel awe are also more curious (Studies 1 and 2), and that this relationship in turn relates to academic outcomes (Study 3). METHOD: In Study 1 (n = 1,005), we used a self-report approach to test the relationship between dispositional awe and curiosity. In Study 2 (n = 100), we used a peer-report approach to test if participants' dispositional awe related to how curious they were rated by their friends. In Study 3, in a sample of 447 high school adolescents we tested if dispositional awe related to academic outcomes via curiosity. RESULTS: We found that dispositional awe was positively related to people's self-rated curiosity (Study 1) and how curious they were rated by their friends (Study 2). In Study 3, we found that dispositional awe was related to academic outcomes via curiosity. CONCLUSIONS: We conclude that among the seven positive emotion dispositions tested, awe was related to unique variance in curiosity, and this link in turn predicted academic outcomes. This work further characterizes awe as an epistemic emotion and suggests that activities that inspire awe may improve academic outcomes.

Socioeconomic and geographical disparities in prescription and illicit opioid-related overdose deaths in Orange County, California, from 2010-2014.

Background: Reports indicate a geographic effect of socioeconomic inequalities on the occurrence of opioid-related fatal overdoses. This study aims to (1) estimate the rates of opioid-related overdoses, (2) estimate the association of benzodiazepine co-ingestion with opioid-related deaths, (3) estimate associations between socioeconomic indicators and opioid-related deaths, and (4) map the distribution of fatal overdoses, in Orange County (OC), California. Methods: An ecologic study was conducted of all opioid- related deaths (1205 total) from 2010 to 2014 obtained from the OC Coroner Division database (1065 OC residents, 55 nonresidents, 85 OC homeless) (analyzed 2016-2017). Rates of opioid overdose, benzodiazepine co-ingestion prevalence, and associations with socioeconomic status (SES; education, poverty, median income) using ZIP code analysis in the residential and homeless communities were calculated. Results: Of 1205 deaths, 904 involved prescription-type opioids, 223 involved heroin, 39 involved both, and 39 not stated; 973 were classified unintentional overdoses, 180 suicides, and 52 undetermined; 49% of cases involved benzodiazepines. Prescription-type opioid and heroin death rates for residents were 5.4/ 100,000 person-years (95% confidence interval [CI]: 5.0-5.8) and 1.2/100,000 person-years (95% CI: 1.0-1.4), respectively. Males, age group 45-54, and Caucasian race had the highest rate (13.6/100,000) of opioid mortality. The highest death rates were seen in homeless adults, at 136/100,000 person-years for prescription-type opioids (95% CI: 99.0-185.5) and 156/100,000 person-years for heroin (95% CI: 116.8-209.5). Conclusions: The burden of prescription-type opioid-related deaths in OC affects all demographics and levels of SES; there is a disproportionately high rate of opioid-related deaths in the OC homeless population.

Utility of common bile duct measurement in ED point of care ultrasound: A prospective study.

BACKGROUND: Measurement of the common bile duct (CBD) is considered a fundamental component of biliary point-of-care ultrasound (POCUS), but can be technically challenging. OBJECTIVE: The primary objective of this study was to determine whether CBD diameter contributes to the diagnosis of complicated biliary pathology in emergency department (ED) patients with normal laboratory values and no abnormal biliary POCUS findings aside from cholelithiasis. METHODS: We performed a prospective, observational study of adult ED patients undergoing POCUS of the right upper quadrant (RUQ) and serum laboratory studies for suspected biliary pathology. The primary outcome was complicated biliary pathology occurring in the setting of normal laboratory values and a POCUS demonstrating the absence of gallbladder wall thickening (GWT), pericholecystic fluid (PCF) and sonographic Murphy's sign (SMS). The association between CBD dilation and complicated biliary pathology was assessed using logistic regression to control for other factors, including laboratory findings, cholelithiasis and other sonographic abnormalities. RESULTS: A total of 158 patients were included in the study. 76 (48.1%) received non-biliary diagnoses and 82 (51.9%) were diagnosed with biliary pathology. Complicated biliary pathology was diagnosed in 39 patients. Sensitivity of CBD dilation for complicated biliary pathology was 23.7% and specificity was 77.9%. CONCLUSION: Of patients diagnosed with biliary pathology, none had isolated CBD dilatation. In the absence of abnormal laboratory values and GWT, PCF or SMS on POCUS, obtaining a CBD measurement is unlikely to contribute to the evaluation of this patient population.

Computerized alcohol screening identified more at-risk drinkers in a level 2 than a level 1 trauma center.

BACKGROUND: Alcohol abuse is recognized as a significant contributor to injury. It is therefore essential that trauma centers implement screening and brief intervention (SBI) to identify patients who are problem drinkers. Although, the utility of SBI in identifying at-risk drinkers have been widely studied in level 1 trauma centers, few studies have been done in level 2 centers. This study evaluates the usefulness of SBI in identifying at-risk drinkers and to investigate the pattern of alcohol drinking among level 2 trauma patients. METHODS: This is a retrospective study of a convenience sample of trauma patients participating in computerized alcohol screening, brief intervention, and referral to treatment (CASI) in an academic level 1 trauma center and a nearby suburban community hospital level 2 trauma center. CASI utilized Alcohol Use Disorders Identification Test (AUDIT) to screen patients. We compared the pattern of alcohol drinking, demographic factors, and readiness-to-change scores between those screened in a level 2 and 1 trauma center. RESULTS: A total of 3,850 and 1,933 admitted trauma patients were screened in level 1 and 2 trauma centers respectively. There was no difference in mean age, gender, and language between the two centers. Of those screened, 10.2% of the level 1 and 14.4% of the level 2 trauma patients scored at-risk (AUDIT 8-19) (p < 0.005). Overall, 3.7% of the level 1 and 7.2% of the level 2 trauma patients had an AUDIT score consistent with dependency (AUDIT > =20) (p < 0.005). After adjusting for age, sex, education, and language, the odds of being a drinker at the level 2 center was two times of those at the level 1 center (p < 0.005). The odds of being an at-risk or dependent drinker at level 2 trauma center were 1.72 times of those at the level 1 center (p < 0.005). CONCLUSIONS: Findings suggest that SBI is effective in identifying at-risk drinkers in level 2 trauma center. SBI was able to identify all drinkers, including at-risk and dependent drinkers at higher rates in level 2 versus level 1 trauma centers. Further studies to evaluate the effectiveness of SBI in altering drinking patterns among level 2 trauma patients are warranted.

Hypertrophic Cardiomyopathy in Youth Athletes: Successful Screening With Point-of-Care Ultrasound by Medical Students.

OBJECTIVES: Hypertrophic cardiomyopathy (HCM) is a life-threatening genetic cardiovascular disease that often goes undetected in young athletes. Neither history nor physical examination are reliable to identify those at risk. The objective of this study is to determine whether minimally trained medical student volunteers can use ultrasound to screen for HCM. METHODS: This was a prospective enrollment of young athletes performed at 12 area high schools and three area colleges, between May 2012 and August 2013. All participants underwent point-of-care ultrasound performed screening for HCM by trained medical students and reviewed by a pediatric cardiologist. An interventricular septum to left ventricular posterior wall ratio greater than 1.25 was considered to be abnormal (positive screen). RESULTS: A total of 2332 participants were enrolled. There were 137 (5.8%) with a positive screening for HCM, of which 7 (5.1%) were confirmed to have HCM by a pediatric cardiologist. In a small cohort with positive screen for HCM, there was a 100% sensitivity (95% confidence interval, 59.04 to 100%) and 4.86% (95% confidence interval, 1.98 to 9.76%) positive predictive value of for having HCM. CONCLUSIONS: Volunteer medical students, using point-of-care ultrasound, were able to effectively screen for HCM in young athletes.

Assessment of Durability of Online and Multisensory Learning Using an Ophthalmology Model.

PURPOSE: To explore the impact of online learning and multisensory small-group teaching on acquisition and retention of specialty knowledge and diagnostic skills during a third-year family medicine rotation. DESIGN: Exploratory, observational, longitudinal, and multiple-skill measures. PARTICIPANTS: Two medical school classes (n = 199) at a public medical school in California. METHODS: Students engaged in online self-study, small-group interactive diagnostic sessions, picture identification of critical pathologic features, and funduscopic simulator examinations. The authors compared performance on testing immediately after online learning with testing at end-rotation, as well as picture identification versus simulator diagnostic ability in students with (n = 94) and without (n = 105) practice tracing contours on whiteboard projections of those same slides depicting fundus pathologic features of common systemic diseases. MAIN OUTCOMES MEASURES: Picture identification, accuracy of funduscopic descriptions, online module post-tests, and end-rotation tests. RESULTS: Proprioceptive reinforcement of fundus pattern recognition significantly reduced the need for remediation for misdiagnosing optic disc edema during end-rotation funduscopic simulator testing, but it had no effect on fundus pattern recognition or diagnostic ability overall. Near-perfect immediate online post-test scores contrasted sharply with poor end-rotation scores on an in-house test (average, 59.4%). Rotation timing was not a factor because the patterns remained consistent throughout the academic school year. CONCLUSIONS: Neither multisensory teaching nor online self-study significantly improved retention of ophthalmic knowledge and diagnostic skills by the end of a month-long third-year rotation. Timing such training closer to internship when application is imminent may enhance students' appreciation for its value and perhaps may improve retention. Pulsed quizzes over time also may be necessary to motivate students to retain the knowledge gained.

Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study.

STUDY OBJECTIVE: Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. METHODS: Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. RESULTS: Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). CONCLUSION: In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.

Patient Motivators for Emergency Department Utilization: A Pilot Cross-Sectional Survey of Uninsured Admitted Patients at a University Teaching Hospital.

BACKGROUND: During the past several decades, emergency department (ED) increasing volume has proven to be a difficult challenge to address. With the advent of the Affordable Care Act, there is much speculation on the impact that health care coverage expansion will have on ED usage across the country. It is currently unclear what the effects of Medicaid expansion and a decreased number of uninsured patients will have on ED usage. OBJECTIVE: We sought to identify the motivators behind ED use in patients who were admitted to a university teaching hospital in order to project the possible impact of health care reform on ED utilization. METHODS: We surveyed a convenience sample of uninsured patients who presented to the ED and were subsequently admitted to the inpatient setting. RESULTS: Our respondents sought care in the ED primarily because they perceived their condition to be a medical emergency. Their lack of insurance and associated costs of care resulted in delays in seeking care, in reduced access, and a limited ability to manage chronic health conditions. Thus, contributing to their admission. CONCLUSIONS: Affordability will reduce financial barriers to health care insurance coverage. However, efficient and timely access to primary care is a stronger determinant of ED usage in our sample. Health insurance coverage does not guarantee improved health care access. Patients may continue to experience significant challenges in managing chronic health conditions.

A retrospective analysis of ethnic and gender differences in alcohol consumption among emergency department patients: a cross-sectional study.

BACKGROUND: Previous studies of alcohol use have recognized several trends in consumption patterns among gender and age yet few have examined ethnic differences. This study examines the intra- and inter-ethnic differences in alcohol consumption among a population of patients seen in the emergency department. METHODS: This is a cross-sectional study conducted in the emergency department in a large urban setting. Information on drinking behavior and ethnicity was collected using the Computerized Alcohol Screening and Brief Intervention (CASI) tool. We explored differences in drinking patterns using a multivariate multinomial logistic regression model. RESULTS: We analyzed the drinking habits of 2,444 patients surveyed between November 2012 and May 2014. The results indicate that when compared to non-Hispanic whites, Asians have the lowest odds of drinking within normal limits or excessively, followed by other Latinos, and Mexicans. Age and gender consistently showed statistically significant associations with alcohol-use. The odds of drinking within normal limits or excessively are inversely associated with age and were lower among females. The predicted probabilities show a marked gender-specific difference in alcohol use both between and within ethnic/racial groups. They also highlight an age-related convergence in alcohol use between men and women within ethnic groups. DISCUSSION: The results of this study show intra-racial/ethnic variability associated with sex and education. The highlighted differences within and between ethnic groups reinforce the need to use refined categories when examining alcohol use among minorities. CONCLUSION: The results of this study confirm some alcohol consumption trends among ethnic minorities observed in literature. It provides empirical evidence of the marked gender differences and highlights an age-related convergence for gender-specific alcohol use. Health-care personnel should be aware of these differences when screening and counseling.

National differences between ED and ambulatory visits for suicidal ideation and attempts and depression.

BACKGROUND: Many suicidal and depressed patients are seen in emergency departments (EDs), whereas outpatient visits for depression remain high. STUDY OBJECTIVE: The primary objective of the study is to determine a relationship between the incidence of suicidal and depressed patients presenting to EDs and the incidence of depressed patients presenting to outpatient clinics. The secondary objective is to analyze trends among suicidal patients. METHODS: The National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey were screened to provide a sampling of ED and outpatient visits, respectively. Suicidal and depressed patients presenting to EDs were compared with depressed patients presenting to outpatient clinics. Subgroup analyses included age, sex, race/ethnicity, method of payment, regional variation, and urban verses rural distribution. RESULTS: Emergency department visits for depression (1.16% of visits in 2002) and suicide attempts (0.51% of visits in 2002) remained stable over the years. Office visits for depression decreased from 3.14% of visits in 2002 to 2.65% of visits in 2008. Non-Latino whites had a higher percentage of ED visits for depression and suicide attempt and office visits for depression than other groups. The percentage of ED visits for suicide attempt resulting in hospital admission decreased by 2.06% per year. CONCLUSION: From 2002 to 2008, the percentage of outpatient visits for depression decreased, whereas ED visits for depression and suicide remained stable. When examined in the context of a decreasing prevalence of depression among adults, we conclude that an increasing percentage of the total patients with depression are being evaluated in the ED, vs outpatient clinics.

Pelvic ultrasonography and length of stay in the ED: an observational study.

OBJECTIVES: We compared emergency physician-performed pelvic ultrasonography (EPPU) with radiology department-performed pelvic ultrasonography (RPPU) in emergency department (ED) female patients requiring pelvic ultrasonography and their outcomes in relation to ED length of stay, ED readmission, and alternative diagnosis, within a 14-day follow-up period. METHODS: This was a prospective, observational study of female patients of reproductive age who required either an EPPU or RPPU for their ED evaluation. We hypothesized that patients receiving EPPU would have a length of stay reduction greater than or equal to 60 minutes, as compared with RPPU. Statistical analyses included an independent-samples t test and multivariate regression modeling to control for factors associated with ED LOS. RESULTS: Eighteen resident physicians performed EPPU, with 15 attending physicians supervising. Forty-eight patients received only EPPU, and 84 patients received only RPPU. In univariate analysis, those who received EPPU had an ED LOS 162 minutes less than those who received RPPU (95% confidence interval, 106-209 minutes). In multivariate analysis controlling for gynecologist consultation, disposition, and pregnancy status, patients who received EPPU had an ED LOS reduction of 108 minutes when compared with RPPU (95% confidence interval, 38-166 minutes). Five patients (10%) who had received EPPU and were discharged from the ED returned to the ED within 2 weeks, but none had alternative diagnoses. CONCLUSIONS: Patients with EPPU had statistically and clinically significant reductions in ED LOS, even when controlling for disposition, gynecologist consultation in the ED, and pregnancy status. No patients in the study had an alternative diagnosis within 2 weeks of EPPU.

High-fidelity simulation enhances ACLS training.

BACKGROUND: Medical student training and experience in cardiac arrest situations is limited. Traditional Advanced Cardiac Life Support (ACLS) teaching methods are largely unrealistic with rare personal experience as team leader. Yet Postgraduate Year 1 residents may perform this role shortly after graduation. PURPOSES: We expanded our ACLS teaching to a "Resuscitation Boot Camp" where we taught 2010 ACLS to 19 pregraduation students in didactic (12 hours) and experiential (8 hours) format. METHODS: Immediately before the course, we recorded students performing an acute coronary syndrome/ventricular fibrillation (VF) scenario. As a final test, we recorded the same scenario for each student. Primary outcomes were time to cardiopulmonary resuscitation (CPR) and defibrillation (DF). Secondary measures were total scenario score, dangerous actions, proportion of students voicing "ventricular fibrillation," 12-lead ST-elevation myocardial infarction (STEMI) interpretation, and care necessary for return of spontaneous circulation (ROSC). Two expert ACLS instructors scored both performances on a 121-point scale, with each student serving as their own control. We used t tests and McNemar tests for paired data with statistical significance at p<.05. RESULTS: Before instruction, average time from arrest to CPR was 112 seconds and to first DF 3.01 minutes. Students scored 45±9/121 points and 9/19 (49%) performed dangerous actions. After instruction, time to CPR was 12 seconds (p=004) and to first DF 1.53 minutes (p=.03). Time to DF was delayed as students showed mastery of bag-valve-mask ventilation before DF. After instruction, students scored 97±4/121 points (p<.0001) with no dangerous actions. Before training, only 4 of 19 (21%) students performed both CPR and DF within 2 minutes, and 3 of these had ROSC. After training, 14 of 19 (74%) achieved CPR+DF≤2 minutes (p=.002), and all had ROSC. Before training, 5 of 19 (26%) students said "VF" and 4 of 19 obtained an ECG, but none identified STEMI. After training, corresponding performance was 13 of 19 "VF" (68%, p=021) and 100% ECG and STEMI identification (p<.05). CONCLUSIONS: This course significantly improved knowledge and psychomotor skills. Critical actions required for resuscitation were much more common after training. ACLS training including high-fidelity simulation decreases time to CPR and DF and improves performance during resuscitation.

Emergency biliary sonography: utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis.

BACKGROUND: Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers. OBJECTIVE: To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound. METHODS: We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis. RESULTS: Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0-0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0-2.7%) with an otherwise negative ultrasound and normal laboratory values. CONCLUSION: The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values.

Characteristics of hospitals diverting ambulances in a California EMS system.

INTRODUCTION: While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics. HYPOTHESIS/PROBLEM: The objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system. METHODS: A retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospital's immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed. RESULTS: Diversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate. CONCLUSIONS: Hospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.

Culture and Awe: Understanding Awe as a Mixed Emotion.

Recent work is establishing awe as an important positive emotion that offers physical and psychological benefits. However, early theorizing suggests that awe's experience is often tinged with fear. How then, do we reconcile emergent positive conceptualizations of awe with its more fearful elements? We suggest that positive conceptualizations of awe may partially reflect modern Western experiences of this emotion, which make up the majority of participant samples when studying awe. To test whether awe contains more fearful qualities outside of Western cultures, we compared participants' experiences of this emotion in China to those in the United States. In a two-week daily diary study (Study 1), Chinese participants reported greater fear than American participants during experiences of awe, but not a comparison positive emotion. In response to a standardized awe induction (Study 2), Chinese participants reported more fear, whereas American participants reported more positive emotions. Physiological changes in autonomic activity differed by culture only for heart rate, but not skin conductance or respiratory sinus arrhythmia. These findings reveal that awe may be experienced as a more fearful, mixed emotion in China than in the United States and suggest that current positive conceptualizations of awe may reflect a disproportionate reliance on modern Western samples. Supplementary Information: The online version contains supplementary material available at 10.1007/s42761-024-00243-3.

Analysis of mental health substance abuse-related emergency department visits from 2002 to 2008.

BACKGROUND: Mental health substance abuse (MHSA)-related visits in the emergency department (ED) are a growing concern. METHODS: This study analyzed MHSA ED visits by age, gender, ethnicity, region, season, and duration of stay between 2002 and 2008 using the National Hospital Ambulatory Care Survey (NHAMCS). The authors used descriptive statistics and examined ED length of stay using a generalized linear model with a log link, and compared length of stay for these visits. RESULTS: Mental health-related visits increased from 6.4% of visits in 2002 to 7.0% in 2008 (P = .002). Substance abuse-related visits increased from 1.8% to 2.1% (P = .004). Substance abuse-related visits accounted for a 49% increase (CI = 0.051-0.23%) in the total mental health visits to the ED. Male visits increased whereas female visits remained unchanged, with non-Latino white males showing the highest increase. The southern United States had the highest increase in MHSA visits. MHSA visits (5.6 hours) were on average 1.2 hours longer than other non-MHSA-related visits (4.4 hours). MHSA-related visits had a higher percentage of all visits on weekends (2.3%) than on weekdays (2.0%; P < .00005). CONCLUSIONS: Concentrated programmatic efforts to decrease the burden of MHSA visits to the ED may reduce the burden of disease.

Assessment of alcohol use patterns among spanish-speaking patients.

OBJECTIVE: The objective of this study was to assess drinking patterns of Spanish-speaking patients using a bilingual computerized alcohol screening and brief intervention (CASI) tablet computer equipped with the Alcohol Use Disorders Identification Test (AUDIT). METHODS: This retrospective study was conducted in a tertiary university hospital emergency department (ED) between 2006 and 2010. Data from 1816 Spanish-speaking ED patients were analyzed using descriptive statistics, the chi-square test for independence, and the Kruskal-Wallis rank sum test for comparisons using quantitative variables. RESULTS: Overall, 15% of Spanish-speaking patients were at-risk drinkers, and 5% had an AUDIT score consistent with alcohol dependency (≥20). A higher percentage of Spanish-speaking males than females were at-risk drinkers or likely dependent. Spanish-speaking males exhibited higher frequency of drinking days per week and higher number of drinks per day compared with females. Among older patients, nondrinking behavior increased and at-risk drinkers decreased. The majority of males and females were ready to change their behavior after the CASI intervention; 61% and 69%, respectively, scored 8-10. CONCLUSIONS: This study indicated that CASI was an effective tool for detecting at-risk and likely dependent drinking behavior in Spanish-speaking ED patients. The majority of patients were ready to change their drinking behavior. More alcohol screening and brief intervention tools should be tested and become readily accessible for Spanish-speaking patients.

A pilot study examining the viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol.

BACKGROUND: Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field. STUDY OBJECTIVE: To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol. METHODS: This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians--paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images. RESULTS: All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6-9.6). CONCLUSION: Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems.