Bereavement scheduling policy for emergency medicine residents: A descriptive pilot study.

Background: The Accreditation Council for Graduate Medical Education has tasked residency programs to prioritize resident wellness, reduce trainee stress, and prevent burnout. Grief and bereavement can significantly impact residents' wellness during difficult clinical training schedules. There are no best practices on how to support residents during this time. Methods: In a split academic county emergency medicine (EM) residency, this pilot study documents a resident-driven change to scheduling practices for bereavement leave. An advisory group of residents, chief residents, and program directors informally polled peer institutions to develop bereavement leave guidelines. Considerations were made to balance resident wellness, education, and patient care in developing a bereavement scheduling policy. Results: The bereavement policy was adopted in January 2023, aiming to "support the resident during a difficult time and reduce concerns around shift coverage" following the death of a family member without impacting sick call. The number of covered days depended on the relationship of the resident to the deceased. Residents covering bereavement days for their peers were financially compensated. During the first 7 months following implementation, five residents utilized the policy. These residents noted this to be the most positive impact on the residency during the past year. Based on resident feedback, the scope was expanded to include grave medical illness of a family member as an implementation criterion. Conclusions: This article outlines the creation, implementation, and benefits of a bereavement scheduling policy within an EM residency. Describing this approach will provide guidance for other residencies to adopt similar wellness-focused strategies.

Targeted Drug Delivery for the Treatment of Abdominal Pain in Chronic Pancreatitis: A Retrospective Case Series.

Abdominal pain secondary to chronic pancreatitis (CP) is difficult to manage and often requires chronic oral opioid therapy (OOT). Targeted drug delivery (TDD) allows for a diminished dose of opioid intake and improved pain levels. TDD has been used in different pain syndromes with only limited reports in CP. OBJECTIVE: The objective of this article is to perform a retrospective review of CP patients treated with TDD versus OOT to compare chronic pain control and consumed morphine-equivalent doses. METHODS: Patients receiving TDD between September 2011 and August 2018 were included. All patients were weaned off oral opioids one week before intrathecal trial and pump implantation. Patients with intrathecal trials providing at least 50% pain relief underwent pump implantation. Data were collected while on OOT and at two weeks, three months, and nine months post-implant. Data were analyzed with Microsoft Excel 365 MSO using means and standard deviations. P-values were calculated using a two-tailed student's t-test with paired two-sample means. RESULTS: Twenty-three patients were analyzed. Pre-trial average pain score was 6.5/10 with a mean improvement with trials greater than 71%. The mean chronic baseline oral morphine milligram equivalents (MME) was 188. The mean MME on TDD at two weeks (0.36), three months (1.39), and nine months (2.47) were significantly lower than OOT. Mean pain scores were 6, 4.9, and 5.6 at two weeks, three months, and nine months, respectively, compared to 6.5 on OOT. DISCUSSION: The results of this study indicate that TDD provides improved pain control with significantly lower opioid doses.

Peripartum Cardiac Arrest with Terminal QRS Distortion: A Case Report.

Introduction: Peripartum cardiac arrest is increasing in incidence. While pulmonary embolism (PE) remains an important cause of peripartum morbidity and mortality, other cardiovascular emergencies such as myocardial infarction (MI) are now the leading cause of pregnancy-related death. Emergency physicians (EP) need to be well versed in subtle electrocardiographic (ECG) signs of coronary ischemia to better care for peripartum patients in cardiac arrest. Case Report: A 38-year-old gravida 2 parity1 female three days post-partum presented in cardiac arrest. After approximately 12 minutes of Advanced Cardiac Life Support including electric defibrillation, the patient experienced sustained return of spontaneous circulation. The physician team was primarily concerned for PE based on an initial ECG demonstrating terminal QRS distortion in V2 but no ST-segment elevation myocardial infarction (STEMI). Computed tomography angiography (CTA) of the chest did not reveal PE. Repeat ECG after CTA demonstrated STEMI criteria, and the patient was emergently taken to the cardiac catheterization laboratory where she was found to have 99% occlusion of the left anterior descending artery. Conclusion: Emergency physicians should have a high index of suspicion for MI when managing peripartum patients in cardiac arrest. The ECG findings specific for coronary-occlusive acute MI but not included in the classic STEMI criteria increase accuracy and prevent delays in diagnosis; however, the clinical uptake of this paradigm has been slow. Early recognition of terminal QRS distortion can help EPs more rapidly diagnose the etiology of cardiac arrest.

Peripheral Nerve Stimulation in Chronic Knee Pain: A Case Series.

Introduction Chronic knee pain is increasing in prevalence and is associated with substantial limitations in functional mobility. Peripheral nerve stimulation (PNS) has been increasingly used to treat various chronic pain conditions. However, there is a paucity of research exploring the potential therapeutic benefit of PNS for chronic knee pain. Methods This research is a retrospective case series of all patients who received PNS for the treatment of chronic knee pain performed at a single-center academic medical institution between March 2021 and June 2022. The primary outcome was percent pain reduction six months after implantation. Outcome data was obtained via chart review and phone calls to patients. Secondary outcomes included percent pain reduction two weeks and two months after implantation and adverse medical events related to the procedure and nerve stimulation. Results Fourteen individual patients received PNS for chronic knee pain during the study period. Three of these patients received bilateral PNS for a total of 17 cases. The mean percent pain reduction six months after implantation was 52% (SD=28.2) (N=12). A total of 75.0% of participants (9/12) reported ≥50% reductions in pain six months after implantation. No adverse events were reported relating to the implantation procedure and/or nerve stimulation. Conclusion PNS is a safe and efficacious treatment modality for chronic knee pain with demonstrated long-term benefit. Further research should clarify patient factors associated with improved treatment response.

Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions.

Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.

High-Altitude Pulmonary Edema in Colorado Children: A Cross-Sectional Survey and Retrospective Review.

Kelly, Timothy D., Maxene Meier, Jason P. Weinman, Dunbar Ivy, John T. Brinton, and Deborah R. Liptzin. High-altitude pulmonary edema in Colorado children: a cross-sectional survey and retrospective review. High Alt Med Biol. 23:119-124, 2022. Introduction: Few studies of high-altitude pulmonary edema (HAPE) are specific to the pediatric population. The purpose of this investigation was to further characterize the radiographic patterns of pediatric HAPE, and to better understand ongoing risk following an initial pediatric HAPE episode. Methods: This study uses both a retrospective chart review and cross-sectional survey. Pediatric patients with HAPE at a single quaternary referral center in the Rocky Mountain Region were identified between the years 2013 and 2020. Patients were eligible if they presented with a clinical diagnosis of HAPE and had a viewable chest radiograph (CXR). Surveys were sent to eligible patients/families to gather additional information relating to family history, puberty, and HAPE recurrence. Results: Forty-two individuals met criteria for clinical diagnosis of HAPE with a viewable CXR. A majority of CXRs (24/42, 57.1%) demonstrated predominant right-sided involvement. Similarly, 24 CXRs (24/42, 57.1%) demonstrated predominant upper lobe involvement. Twenty-one (21/42, 50%) surveys were completed. A minority of individuals went on to experience at least one other HAPE episode (8/19, 42.1%). Conclusion: The most common radiographic pattern seen in pediatric HAPE is pulmonary edema that favors the right lung and upper lobes. After an initial HAPE presentation, some children will experience additional HAPE episodes.