Agricultural workers in meatpacking plants presenting to an emergency department with suspected COVID-19 infection are disproportionately Black and Hispanic.

OBJECTIVE: Facilities that process and package meat for consumer sale and consumption (meatpacking plants) were early sites of coronavirus disease 2019 (COVID-19) outbreaks. The aim of this study was to characterize the association between meatpacking plant exposure and clinical outcomes among emergency department (ED) patients with COVID-19 symptoms. METHODS: This was a retrospective cohort study of patients presenting to a single ED, from March 1 to May 31, 2020, who had: 1) symptoms consistent with COVID-19 and 2) a COVID-19 test performed. The primary outcome was COVID-19 positivity, and secondary outcomes included hospital admission from the ED, ventilator use, intensive care unit (ICU) admission, hospital length of stay (LOS; <48 or ≥48 h), and mortality. RESULTS: Patients from meatpacking plants were more likely to be Black or Hispanic than the ED patients without this occupational exposure. Patients with a meatpacking plant exposure were more likely to test positive for COVID-19 (adjusted relative risk [aRR] = 2.37, 95% confidence interval [CI] = 1.59 to 3.53) but had similar rates of hospital admission (aRR = 0.94, 95% CI = 0.82 to 1.07) and hospital LOS (aRR = 0.76, 95% CI = 0.45 to 1.23). There was no significant difference in ventilator use among patients with meatpacking and nonmeatpacking plant exposure (8.2% vs. 11.1%, p = 0.531), ICU admissions (4.1% vs. 12.0%, p = 0.094), and mortality (2.0% vs. 4.1%, p = 0.473). CONCLUSIONS: Workers in meatpacking plants in Iowa had a higher rate of testing positive for COVID-19 but were not more likely to be hospitalized for their illness. These patients were disproportionately Black and Hispanic.

International travel is not a significant risk of exposure for patients at a Midwestern United States travel clinic.

The Novel Coronavirus (SARS-CoV-2) was introduced into the United States via travel from Asia and Europe, although the extent of the spread of the disease was limited in the early days of the pandemic. Consequently, international travel may have played a role in the transmission of the disease into Iowa. This study seeks to determine how preferences for international travel changed as novel Coronavirus Disease (COVID-19) spread throughout the world and if any of these returning travelers developed COVID-19 as a result of their trips. This is a retrospective chart review of patients presenting to a travel clinic in Bettendorf, Iowa for pre-travel advice and vaccinations. From October 2019 to March 2020, four hundred twelve (n = 412) patients presented to the clinic. Intended travel to the Western Pacific region (China, Japan, Korea, etc.) decreased dramatically during the study period. All 412 patients were followed in the electronic medical record for the period after their planned travel and only three (3) presented for COVID-19 testing. Two (2) tested positive, and both of these infections were linked to workplace exposures and not due to travel. News of the growing pandemic and travel warnings likely altered patients' travel plans and decreased travel to the most affected regions of the world in the early months of the COVID-19 pandemic. Based on our study, travel was not a significant source of COVID-19 exposure for patients seen at this clinic.

End-tidal CO2 Monitoring is Available in Most Community Hospitals in a Rural State: A Health System Survey.

INTRODUCTION: Procedural sedation and analgesia (PSA) provides safe and effective relief for pain, anxiety and discomfort during procedures performed in the emergency department (ED). Our objective was to identify hospital-level factors associated with routine PSA capnography use in the ED. METHODS: This study was a cross-sectional telephone survey of ED nurse managers and designees in a Midwestern state. Respondents identified information about hospital infrastructure, physician staffing, family practice (FP) physicians only, board-certified emergency physicians (EPs) only (or both), and critical intervention capabilities. Additional characteristics including ED volume and hospital designation (i.e., rural-urban classification) were obtained from the Centers for Medicare and Medicaid Services and the state hospital association database, respectively. The primary outcome was reported use of PSA capnography. We conducted univariate analyses (relative risks, 95% confidence interval [CI]) to identify associations between hospital-level characteristics and PSA capnography use. RESULTS: We had an overall response rate of 98% (n=118 participating hospitals). The majority of EDs were in rural settings (78%), with a median of 5,057 visits per year (interquartile range 2,823-14,322). Nearly half of the EDs were staffed by FP physicians only, while 16% had board-certified EPs only. Nearly all hospitals (n=114, 97%), reported using continuous capnography for ventilated patients, and 74% reported use of capnography during PSA. Urban hospitals were more likely to use PSA capnography than critical access hospitals (relative risk 1.45; 95% CI, 1.22-1.73), and PSA capnography use increased with each ED volume quartile. Facilities with only EPs were 1.46 (95% CI, 1.15-1.87) times more likely to use PSA capnography than facilities with FP physicians only. CONCLUSION: Continuous capnography was available in nearly all EDs, independent of size, location or patient volume. The implementation of capnography during PSA was less penetrant. Smaller, rural departments were less likely than their larger, urban counterparts to implement these national guidelines. Rurality and hospital size may be potential institutional barriers to capnography implementation.

Physician Age and Performance on the American Board of Emergency Medicine ConCert Examination.

OBJECTIVE: This study was undertaken to expand on results from a 2014 study on the association between physician age and performance on the American Board of Emergency Medicine (ABEM) ConCert examination. METHODS: This was a retrospective, longitudinal growth study comparing performance on the ConCert examination and physicians' ages at the time of examination. All examination attempts from 1990 to 2016 made by residency-trained physicians were eligible for inclusion. Multilevel growth models were constructed to examine the relationship between age at time of examination and performance, controlling for physician characteristics. RESULTS: The study group included 15,533 examination attempts by 12,786 physicians. The mean (±SD) age of the physicians across all examination administrations was 45.02 (±5.18) years (range = 35 to 72 years). The mean (±SD) ConCert examination score across all administrations was 85.39 (±5.71; range = 51 to 100). Among first-time ConCert examination takers, older age was associated with lower examination scores (r = -0.25, p < 0.0001). Across all examination attempts, age was negatively correlated to examination scores (r = -0.24; p < 0.0001). CONCLUSIONS: After physician characteristics were controlled for, there was an association between advancing age and declining performance on the ABEM ConCert examination. This information may be important to the individual physician to develop targeted competency assessment and professional development.

Ethanol Values During College Football Season: University Policy Change and Emergency Department Blood Ethanol Values From 2006 Through 2014.

BACKGROUND: Tailgating is popular at many college football games. However, it is known to contribute to binge drinking and alcohol intoxication, which are common public health challenges. OBJECTIVE: To use laboratory data to measure changes in plasma ethanol levels observed in a large state university emergency department after a series of reforms were enacted to reduce binge drinking. METHODS: We performed a retrospective chart review on all serum ethanol levels measured at the University of Iowa Hospitals and Clinics on weekends from 2006 through 2014. Data were analyzed by multivariable logistic regression after controlling for significant covariates. RESULTS: A total of 5437 patients had ethanol levels recorded on weekends. After the implementation of policy changes, there was a significant reduction in the adjusted odds ratio (AOR) of ethanol values reported in the severe intoxication range (≥240 mg/dL; AOR = 0.77; 95% confidence interval [CI], 0.64-0.92). CONCLUSION: The policy changes implemented in 2009 in an attempt to reduce binge drinking are associated with a decreased likelihood of an ethanol result being in the severe intoxication range.

Injury incidence and predictors on a multiday recreational bicycle tour: The Register's Annual Great Bike Ride Across Iowa, 2004 to 2008.

OBJECTIVE: The "Register's Annual Great Bike Ride Across Iowa" (RAGBRAI) is a 7-day recreational bicycle ride with more than 10,000 participants covering 500 miles. The heat and humidity of late July in Iowa, the prevalence of amateur riders, and the consumption of alcohol can combine creating the potential for a significant number of injuries. The purpose of this study is to determine the type, quantity, and severity of injuries on RAGBRAI and gather data on the factors related to these incidents. METHODS: This retrospective chart review examined ambulance "run sheets" for patients requiring transport to the hospital from the bike route between 2004 and 2008. These run sheets included name, age, chief complaint, anatomic location of injuries, medications administered, procedures performed, and a full narrative describing the initial scene, patient's account of the incident, services provided, and ongoing condition of the patient while en route to the hospital. Chi-square tests, Pearson's correlation tests, and t tests were applied to determine significant statistical outcomes. RESULTS: From 2004 to 2008, Care Ambulance Inc provided on-route medical services for 419 RAGBRAI participants. Of these participants, 190 (45.3%) required transport to a local hospital by Care Ambulance Inc. Females were more likely to require transport, as they comprised 46.3% of transported patients while only representing 35% of all RAGBRAI participants (P = .001). For men, increasing age was a significant predictor of transport, particularly males between the ages of 60 and 69 years old (P = .01). Of the 148 run sheets where mechanism of incident was documented, 114 incidents were caused by rider factors (77.0%), 29 by road factors (19.6%), and 5 by bicycle factors (3.4%). Higher heat indexes were correlated with an increased number of dehydration cases (r = 0.979, P = .02). Of participants who reported with minor injuries to a mobile first aid station and did not require transport, 90.1% had not imbibed any alcohol. Bony injuries were more common above the waistline as 39/45 (86.7%) fractures occurred to the clavicle, shoulder/proximal humerus, hand, or head. The most common bony injury each year of RAGBRAI was a clavicle fracture, which represented 44.4% of all recorded fractures from 2004 to 2008. Lacerations and abrasions were also more common above the waist, as 63.5% (127/200) of soft tissue injuries requiring treatment were either to the head or upper extremities. No specific event day showed any correlation with increased injury (P >.05). CONCLUSIONS: This study suggests that females and older males are more likely to require transport for injuries sustained on RAGBRAI, the majority of injuries occur around the head and upper extremities, dehydration case load is correlated with heat index, and that incidents are usually caused by rider factors. This research could be used by multiday recreational bicycle tour organizers to continue educating riders on riding carelessness and etiquette and prepare medical services for certain quantities and types of injuries.

Travel-related infections.

Infections in travelers returning from international destinations are a common problem for emergency physicians. A careful travel history can help to distinguish the traveler's risk of having contracted an exotic infection, including malaria, dengue fever, and typhoid fever. The most common travel-related infection is traveler's diarrhea. A discussion of typical and rare conditions is provided, grouped by the three most common chief complaints of fever, diarrhea, and rash.

The laryngeal tube device: a simple and timely adjunct to airway management.

INTRODUCTION: Endotracheal intubation (ETI) is a motor skill that demands practice. Emergency medical service providers with limited intubation experience should consider using airway adjuncts other than ETI for respiratory compromise. Prehospital ETI has been recently interrogated by evidence exposing worsened patient outcomes. The laryngeal tube (LT) airway was approved by the Food and Drug Administration in 2003 for use in the United States. Using difficult airway-simulated models, we sought to describe the time difference between placing the ETI and LT and the successful placement of each adjunct in varied levels of healthcare providers. METHODS: Emergency medicine resident physicians, fourth year medical students, and paramedic students were asked to use both ETI and the LT. Subjects were timed (seconds) on ETI and LT placement on 2 different simulators (AirMan and SimMan; Laerdal Co, Wappingers Falls, NY). After ETI was complete, they were given 30 seconds to review an instructional card before placement of the LT. We measured placement time and successful placement of the device for ETI vs LT. Successful placement in the manikin was defined by a combination of breath sounds, chest rise, and absence of epigastric sounds. RESULTS: Overall mean placement time in the AirMan and SimMan for ETI was 76.4 (95% confidence interval [CI], 63.3-89.5) and 45.9 (95% CI, 41.0-50.2) seconds, respectively. Mean placement time for the LT in the AirMan and SimMan was 26.9 (95% CI, 24.3-29.5) and 20.3 (95% CI, 18.1-22.5) seconds, respectively. The time difference between ETI and LT for both simulators was significant (P < .0001). Successful placement of the LT compared with ETI in the AirMan was significant (P = .001). CONCLUSIONS: A significant time difference and simplicity exists in placing the LT, making it an attractive device for expeditious airway management. Further studies will need to validate the LT effectiveness in ventilation and oxygenation; however, its uncomplicated design allows for successful use by a variety of healthcare providers.

Principles of antibiotic treatment of community-acquired pneumonia in the outpatient setting.

Community-acquired pneumonia (CAP) is a common illness with high rates of morbidity and mortality. Nearly 80% of the treatment for this condition is provided in the outpatient setting. Among the etiologic agents associated with bacterial CAP, the predominant pathogen is Streptococcus pneumoniae. Treatment of CAP for the most part is empirical; therefore, any antibiotic treatment should cover both typical and atypical pathogens. The beta-lactams have historically been considered standard therapy for the treatment of CAP. However, the impact of rising resistance rates is now a primary concern facing physicians. For patients with comorbidities or recent antibiotic therapy, current guidelines recommend either combination therapy with a beta-lactam and a macrolide or an antipneumococcal fluoroquinolone alone. Fluoroquinolones are broad-spectrum antibiotics that exhibit high levels of penetration into the lungs and low levels of resistance. Evidence from clinical trials indicates clinical success rates of > 90% for moxifloxacin, gatifloxacin, and levofloxacin in the treatment of CAP due to S pneumoniae. Data from comparative clinical trials suggest fluoroquinolone monotherapy is as efficacious as beta-lactam-macrolide combination therapy in the treatment of CAP patients. The respiratory fluoroquinolone levofloxacin has also been shown to be effective in CAP patients for the treatment of macrolide-resistant S pneumoniae. The use of azithromycin, telithromycin, and fluoroquinolones in short-course regimens has been shown to be efficacious, safe, and tolerable in patients with CAP. Based on clinical evidence, high-dose, short-course therapies may represent a significant advance in the management of CAP.