Homemade phantoms improve ultrasound-guided vein cannulation confidence and procedural performance on patients.

BACKGROUND: Ultrasound-guided vein cannulation is an essential skill in emergency medicine. Prohibitive costs of commercial ultrasound phantoms limit the ability to adequately train residents. We assess the clinical utility of homemade phantoms for medical education. METHODS: Eighteen emergency medicine residents each performed 10 ultrasound-guided IV attempts on patients, half of the attempts before and half after a training course using two homemade ultrasound phantoms with 14 total Penrose drains. We conducted a prospective feasibility study using pre- and post-training surveys comparing confidence and success rates of IV cannulation attempts on patients. RESULTS: Residents demonstrated an improvement in successful ultrasound-guided peripheral vein cannulations from an average of 47.8% during the first five attempts to 71.1% in the last five attempts. No benefit was noted from the first to the fifth attempts, nor from the six to the tenth attempts, suggesting minimal benefit from experience early on. Residents reported increased confidence in performing ultrasound-guided venous cannulation on patients, identifying the correct probe, adjusting gain and depth, visualizing veins in short and long axis, differentiating arteries from veins, and vein cannulation on a phantom model. CONCLUSION: Homemade ultrasound phantoms are cost effective, increase confidence, and improve emergency medicine residents' ability to perform ultrasound-guided vein cannulation.

Phlegmasia cerulea dolens causing compartment syndrome.

BACKGROUND: Phlegmasia cerulea dolens (PCD) is a rare condition characterized by a severely swollen, cyanotic, blue extremity due to a large proximal (iliofemoral) deep venous thrombosis extending into the collateral veins. Mortality in PCD ranges 20-40%. Due to severely compromised venous drainage, compartment pressures can rapidly increase 16-fold within 6 h, but rarely result in arterial compromise. CASE REPORT: We present a case of a middle-aged woman with no prior history of deep venous thrombosis, with a blue swollen left leg in intractable severe pain unresponsive to 3 doses of hydromorphone. Her pain was successfully alleviated with IV Lidocaine. Patient was found to have phlegmasia cerulea dolens resulting in compartment syndrome of her left leg. Although the patient initially had no motor function, after catheter-directed thrombolysis and emergent thrombectomy, she regained her motor function and made a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Phlegmasia cerulea dolens complicated by severe compartment syndrome is a rare entity. Prompt recognition and treatment are necessary to prevent irreversible limb ischemia and associated morbidity and mortality. IV Lidocaine may be considered as an option for analgesia for such patients.

Wide complex tachycardia in dialysis patients is not always hyperkalemia.

BACKGROUND: Flecainide is a commonly used IC antiarrhythmic. Clinical presentations of Flecainide toxicity are not commonly described. CASE REPORT: A 62 year old man on dialysis presented for evaluation of outpatient bradycardia and hypotension. In the ED, patient had wide-complex rhythm with heart rates ranging from 76 to 127. The previous day, Flecainide and Metoprolol were discontinued and patient was dialyzed and discharged. The patient was treated empirically for possible hyperkalemia. No significant change in ECG was noted with administration of calcium. Sodium bicarbonate produced questionable benefit. Potassium level was 4.6 mmol/L. Cardiac rhythm fluctuated between sinus rhythm and wide complex tachycardia in the ED & ICU. Flecainide level was 2.1 µg/ml (normal <1 µg/ml). Toxicity developed despite previous discontinuation and dialysis prior to presentation because of Flecainide's large volume of distribution and lipopholicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although Flecainide toxicity is uncommon, it has a high mortality rate, requiring early identification and treatment. Flecainide toxicity can develop in patients with hepatic or renal insufficiency, and can manifest with ventricular tachycardia or bradycardia. If suspicion of Flecainide toxicity arises, lidocaine and procainamide should be avoided to prevent further sodium channel blockade. Absence of response to calcium for a very wide complex QRS should raise clinicians' suspicion that WCT is not due to hyperkalemia, emphasizing the importance of reviewing patients' home medications. Sodium bicarbonate should be administered early to treat widened QRS. Amiodarone, intralipid emulsion therapy and ECMO may be considered in severe cases.

Resolution of status epilepticus after ketamine administration.

BACKGROUND: Status Epilepticus is the most common non-traumatic neurologic emergency in childhood. Current algorithms prioritize the use of benzodiazepines as first line treatment followed by Levetiracetam or Valproic Acid, possibly Fosphenytoin and eventually high dose Propofol and intubation. CASE REPORT: A 9-month old girl was brought to the emergency department with a continuous seizure involving the right upper and lower extremity for 45 min prior to arrival. Patient received a dose of rectal Diazepam, intramuscular Midazolam, 2 doses of Lorazepam, Levetiracetam, Fosphenytoin and 2 additional doses of Lorazepam. The seizure remained refractory and generalized. In anticipation of intubation, and because of its action on the NMDA receptor, Ketamine (1 mg/kg IV) was administered. The clonic movements and eye deviations stopped. Patient was intubated for airway protection, sedated with Propofol, then admitted to the PICU. EEG showed no evidence of a seizure pattern. Labs (CBC, CMP, COVID) were unremarkable except for WBC 24.5, blood glucose of 346 and CO2 of 17 with normal anion gap. Urinalysis showed a urinary tract infection. Patient was at her baseline on 1 week post-discharge re-evaluation. Ketamine theoretically may abort seizures through blockade of NMDA receptors which are unregulated in status epilepticus. To date, no randomized controlled trials have been reported. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ketamine may have a role in treating status epilepticus. It may be considered for induction for rapid sequence intubation and possibly as a third or fourth line agent in refractory cases.

Workplace Violence in Emergency Departments in Turkey.

Background Studies on workplace violence against physicians in emergency departments (EDs) in Turkey are lacking. Methods To describe the frequency and types of workplace violence, a 34-question online survey of the past 12 months was sent to physicians working in EDs in Turkey. Types of violence were categorized as verbal threats, physical assaults, confrontation, stalking, and sexual harassment. Results A total of 366 physicians completed the survey; 4 were excluded (minimum 20 hours/week). Sixty-two percent of respondents were men. Ninety-nine percent reported verbal abuse and 54% reported physical violence. Family members, not patients, were the most common perpetrators of every form of workplace violence. Hospitals limiting the number of visitors and loitering had 14% reduction in physical threats. Only 23% of respondents indicated that their hospital offered information about preventing and managing workplace violence even though 86% noted interest. Only 1% never had fear, even though 89% indicated they had security staff. Over 89% felt that hospital security was lacking in number and ability to protect. For 82%, workplace violence affected their ability to provide patient care. Ninety percent indicated that current laws do not adequately protect them. There was also no statistically significant difference in any type of workplace violence based on the timing or length of shifts, type of hospital, or number of hours worked. Of all types of violence reported, only stalking demonstrated a statistically significant difference between men and women. Conclusion Workplace violence is a real danger for physicians working in EDs in Turkey, similar to other countries, demonstrating that this problem transcends borders. Further studies should assess root causes of violent behaviors of patients and their visitors, as well as possible (administrative, social, and legal) mechanisms to minimize such violence. Hospitals that limited the number of visitors and empowered security officers were associated with decreased violence.

Isolated Tachycardia Presenting After Pfizer-BioNTech COVID-19 Vaccination.

A 29-year-old woman presented to the emergency department with palpitations and a heart rate of over 140 beats per minute that started approximately six to eight hours after administration of her second COVID-19 vaccination. Many side effects have been associated with the administration of vaccines. We present the first documented case of tachycardia and palpitations, in the absence of other signs or symptoms, presenting within hours of receiving the Pfizer-BioNTech COVID-19 vaccination. Clinicians should be aware that this appears to be benign and resolved within 24 hours in our patient.

Homemade cardiac and vein cannulation ultrasound phantoms for trauma management training in resource-limited settings.

Ultrasound has become an essential skill for trauma management in resource-limited areas. Prohibitive costs of commercial ultrasound phantoms limit the abilities of many hospitals to adequately train health-care providers. We assessed the utility of homemade phantoms in a wartime setting. Thirty physicians and technicians enrolled in a medical training course, sponsored by the Syrian American Medical Society (SAMS). Ultrasound simulation models were created onsite by using psyllium, gelatin, a hotel coffee maker, and Pyrex dishes. Lamb hearts were used to teach visual diagnosis and subsequent drainage of pericardial effusions. Penrose drains were used to teach vein identification and cannulation under dynamic ultrasound guidance. Two phantoms with a total of 14 penrose drains were created, serving 30 health-care providers. Feedback from participants was positive and within one month of the course, two cases of pericardial tamponade were diagnosed and surgically treated in the largest trauma hospital operated by SAMS. CONTEXT: In resource-limited environments, ultrasound phantoms (models) are cost-prohibitive. AIMS: We assessed the utility of homemade phantoms in a resource-limited wartime setting to train Syrian physicians and technicians in vein cannulation and limited cardiac ultrasonography. SETTINGS AND DESIGN: Thirty physicians and technicians enrolled in a medical training course, sponsored by SAMS. METHODS: Ultrasound simulation models were created onsite by using psyllium, gelatin, a hotel coffee maker, and Pyrex dishes. Lamb hearts were used to teach visual diagnosis and subsequent drainage of pericardial effusions. Penrose drains were used to teach vein identification and cannulation under dynamic ultrasound guidance. Two phantoms with a total of 14 penrose drains were created, serving 30 health-care providers. STATISTICAL ANALYSIS USED: N/A. RESULTS: Feedback from participants was positive and within one month of the course, two cases of pericardial tamponade were diagnosed and surgically treated in the largest trauma hospital operated by SAMS. CONCLUSIONS: Homemade ultrasound phantoms are a promising cost-effective means for meeting an educational gap in ultrasound training, particularly for resource-limited hospitals and possibly more broadly in residency education.

Siblings with pediatric sodium chlorite toxicity causing methemoglobinemia, renal failure and hemolytic anemia.

INTRODUCTION: Over the past decade, Miracle Mineral Solution (sodium chlorite) has been promoted as a cure-all for many conditions. CASE REPORT: A 9-year-old boy presented with his brother after they accidentally ingested a small amount of undiluted 22.4% sodium chlorite. Symptoms included nausea, vomiting, diarrhea, and dyspnea. Oxygen saturation remained 71% despite supplemental oxygen (15L/min). The patient was noted to have dark chocolate-appearing blood, minimal urine output, diffuse pallor and cyanosis. He developed methemoglobinemia, renal failure requiring renal replacement therapy and hemolysis requiring blood transfusion. DISCUSSION: These are the 7th and 8th reported cases of sodium chlorite toxicity by ingestion and the second and third in children. Takeaway for Physicians: Miracle Mineral Solution is a commonly purchased potentially lethal compound that can cause methemoglobinemia with respiratory failure, hemolytic anemia requiring transfusion and renal failure requiring dialysis.

Global Emergency Medicine Fellowships: Survey of Curricula and Pre-Fellowship Experiences.

INTRODUCTION: Lack of accreditation requirements affords global emergency medicine (GEM) fellowships the flexibility to customize curricula and content. A paucity of literature exists describing the state of GEM fellowship programs. We describe the current state of GEM fellowship curricula including which components are commonly included, and highlighting areas of higher variability. METHODS: We identified GEM fellowships and invited them to participate in a web-based survey. Descriptive statistical analysis was performed. RESULTS: Of the 46 fellowship programs invited to participate, 24 responded; one duplicate response and one subspecialty program were excluded. The 22 remaining programs were included in the analysis. Nineteen programs (86%) offer a Masters in Public Health (MPH) and 36% require an MPH to graduate. Additionally, 13 programs (59%) offered graduate degrees other than MPH. Fellows average 61 clinical hours per month (95% confidence interval, 53-68). Time spent overseas varies widely, with the minimum required time ranging from 2-28 weeks (median 8 weeks; interquartile range [IQR] 6,16) over the course of the fellowship. The majority of programs offer courses in tropical medicine (range 2-24 weeks, median 4 weeks) and the Health Emergencies in Large Populations course. Only 32% of programs reported offering formal ultrasound training. Fellows averaged 1.3 research projects prior to fellowship and median of 2.5 during fellowship (IQR 1,3). While the majority of GEM fellowship graduates worked at US academic centers (59%), 24% worked in US community hospitals, 9% worked for non-profit organizations, and 9% worked internationally in clinical practice. CONCLUSION: Our results highlight the wide variability of curricular content and experiences offered by GEM fellowships.

Effect of race and insurance on outcome of pediatric trauma.

OBJECTIVES: This study sought to determine if insurance or race status affect trauma outcomes in pediatric trauma patients. METHODS: Using the National Trauma Data Bank (NTDB; v6.2), the following variables were extracted: age (0-17 years), payment type (insured, Medicaid/Medicare, or self-pay), race (white, Black/African American, or Hispanic), Injury Severity Score (ISS > 8), type of trauma (blunt or penetrating), and discharge status (alive or dead). Data were analyzed using logistic regression. RESULTS: Of the 70,781 patient visits analyzed, 67% were insured, 23% were Medicaid/Medicare, and 10% were self-pay. Self-pay patients had higher mortality (11%, compared to Medicaid/Medicare at 5% and insured at 4%; p < 0.001). African Americans and Hispanics also had higher mortality (7 and 6%) compared to whites (4%; p < 0.001). Self-pay patients more likely suffered penetrating trauma than insured patients (12% vs. 4%; p < 0.001), and mortality for penetrating trauma self-pay patients was 29%, compared to only 11% for penetrating trauma insured patients (p < 0.001). The mortality rate varied from a low of 3% for insured whites, to 18% for self-pay African Americans. Logistic regression (including race, insurance status, injury type, and ISS) revealed that African Americans and Hispanics both had an increased risk of death compared to whites (African American odds ratio [OR] = 1.37, Hispanic OR = 1.20). Medicaid/Medicare patients had a slightly increased risk of death with OR = 1.14, but self-pay patients were almost three times more likely to die (adjusted OR = 2.92). CONCLUSIONS: After controlling for ISS and type of injury, mortality disparity exists for uninsured, African American, and Hispanic pediatric trauma patients. Although the reasons for this are unclear, efforts to decrease these disparities are needed.