Outreach to people who survive opioid overdose: Linkage and retention in treatment.

Cognitive motivation theories contend that individuals have greater readiness for behavioral change during critical periods or life events, and a non-fatal overdose could represent such an event. The objective of this study was to examine if the use of a specialized mobile response team (assertive outreach) could help identify, engage, and retain people who have survived an overdose into a comprehensive treatment program. We developed an intervention, consisting of mobile outreach followed by medication and behavioral treatment, in Houston Texas between April and December 2018. Our primary outcome variables were the level of willingness to engage in treatment, and percent who retained in treatment after 30 and 90 day endpoints. We screened 103 individuals for eligibility, and 34 (33%) elected to engage in the treatment program, while two-thirds chose not to engage in treatment, primarily due to low readiness levels. The average age was 38.2 ± 12 years, 56% were male, 79% had no health insurance, and the majority (77%) reported being homeless or in temporary housing. There were 30 (88%) participants still active in the treatment program after 30 days, and 19 (56%) after 90 days. Given the high rates of relapse using conventional models, which wait for patients to present to treatment, our preliminary results suggest that assertive outreach could be a promising strategy to motivate people to enter and remain in long-term treatment.

Physician reentry-A timely topic for emergency medicine.

As physician workforce shortages persist, physician reentry is an important and timely issue for the specialty of emergency medicine. Physician reentry is defined as a return to clinical practice following an extended period of clinical inactivity not resulting from discipline or impairment. This review provides a general overview of the physician reentry published literature with a focus on the specialty of emergency medicine. Transition into a non-clinical position, personal health, family issues, and career dissatisfaction all contribute to physicians leaving the workforce voluntarily. Previously, the majority of reentry physicians did not pursue additional training prior to returning to the workforce; however, regulatory agencies are now increasingly requiring additional training, standardized testing, and fitness to practice evaluations prior to restarting clinical work. The burden of proof is on the reentry physician to meet the appropriate requirements for licensure, certification, and credentialing prior to returning to clinical work.

Acute Abdominal Pain in the Bariatric Surgery Patient.

Obesity is present in epidemic proportions in the United States, and bariatric surgery has become more common. Thus, emergency physicians will undoubtedly encounter many patients who have undergone one of these procedures. Knowledge of the anatomic changes specific to these procedures aids the clinician in understanding potential complications and devising an organized differential diagnosis. This article reviews common bariatric surgery procedures, their complications, and the approach to acute abdominal pain in these patients.

Emergency medicine resident clinical hours: a national survey.

BACKGROUND: Emergency medicine (EM) residency programs have significant scheduling flexibility. As a result, there is potentially significant variation in scheduling practices. Few studies have previously sought to describe this variation. It is unknown how this affects training time in the emergency department. OBJECTIVES: The purpose of this study was to describe the current variation in clinical training practices through clinical hour, shift length, and rotation survey data. METHODS: A 21-item questionnaire was distributed to all allopathic EM training programs utilizing an online survey during the 2011-2012 academic year. Questions included demographic data, number of EM rotations per year, shifts, average hours, shift length, and scheduling practices. RESULTS: A total of 122 responses were received and 82 programs were analyzed (51.6% of 159 allopathic programs). EM residents work, on average, 45.50 h per week. Postgraduate year 1-3 programs utilizing 28-day schedules averaged two additional EM rotations and 338.2 more clinical EM hours compared with calendar-month rotations. The residents of 4-year programs work approximately 1300 additional hours during residency, with an average of 1279.26 h and 7.9 clinical EM rotations in the fourth year. Clinical hour ranges of 2670-5112 and 4248-6113 were observed for 3-year and 4-year programs, respectively. CONCLUSIONS: There are different scheduling modalities used to create resident schedules. This flexibility results in a large amount of diversity in scheduling practices, with certain patterns allowing for significantly more clinical time. This may result in a vastly different training experience for EM residents.

A multicenter study of the family educational rights and privacy act and the standardized letter of recommendation: impact on emergency medicine residency applicant and faculty behaviors.

BACKGROUND: Residency applicants have the right to see letters of recommendation written on their behalf. It is not known whether applicants are affected by waiving this right. OBJECTIVES: Our multicenter study assessed how frequently residency applicants waived their FERPA rights to view their letters of recommendation, and whether this affected the ratings they were given by faculty. METHODS: We reviewed all ERAS-submitted letters of recommendation to 14 ACGME-accredited programs in 2006-2007. We collected ERAS ID, program name, FERPA declaration, standardized letter of recommendation (SLOR) use, and SLOR Global Assessment ranking. The percentage of applicants who waived their FERPA rights was determined. Chi-square tests of independence assessed whether applicants' decision to waive their FERPA rights was associated with their SLOR Global Assessment. RESULTS: We examined 1776 applications containing 6424 letters of recommendations. Of 2736 letters that specified a Global Assessment, 2550 (93%) applicants waived their FERPA rights, while 186 did not. Of the applicants who chose not to waive their rights, 45.6% received a ranking of Outstanding, 35.5% Excellent, 18.3% Very Good, and 1.6% Good. Of applicants who waived their FERPA rights, 35.1% received a ranking of Outstanding, 49.6% Excellent, 13.7% Very Good, and 1.6% Good. Applicants who did not waive their FERPA rights were more likely to receive an Outstanding Assessment (P  =  .003). CONCLUSIONS: The majority (93%) of residency applicants waived their FERPA rights. Those who did not waive their rights had a statistically higher chance of receiving an Outstanding Assessment than those who did.

The 2013 Model of the Clinical Practice of Emergency Medicine.

In 2001, "The Model of the Clinical Practice of Emergency Medicine" was first published. This document, the first of its kind, was the result of an extensive practice analysis of emergency department (ED) visits and several expert panels, overseen by representatives from six collaborating professional organizations (the American Board of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, the Residency Review Committee for Emergency Medicine, the Council of Emergency Medicine Residency Directors, and the Emergency Medicine Residents' Association). Every 2 years, the document is reviewed by these organizations to identify practice changes, incorporate new evidence, and identify perceived deficiencies. For this revision, a seventh organization was included, the American Academy of Emergency Medicine.

The treatment of cutaneous abscesses: comparison of emergency medicine providers' practice patterns.

INTRODUCTION: Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions. This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting. METHODS: Four hundred and seventy-four surveys were distributed to 15 EDs across the United States. Participants were queried about their level of training and practice environment as well as specific questions regarding their management of cutaneous abscesses in the ED. RESULTS: In total, 350 providers responded to the survey (74%). One hundred eighty-nine respondents (54%) were attending physicians, 135 (39%) were residents, and 26 (7%) were midlevel providers. Most providers (76%) used narcotics for pain management, 71% used local anesthetic over the roof of the abscess, and 60% used local anesthetic in a field block for pain control. More than 48% of responders routinely used irrigation after (I&D). Eighty-five percent of responders used a linear incision to drain the abscess and 91% used packing in the wound cavity. Thirty-two percent routinely sent wound cultures and 17% of providers routinely prescribed antibiotics. Most providers (73%) only prescribed antibiotics if certain historical factors or physical findings were present on examination. Antibiotic treatment, if used, favored a combination of 2 or more drugs to cover both Streptococcus and methicillin-resistant Staphylococcus aureus (47%). Follow-up visits were most frequently recommended at 48 hours unless wound was concerning and required closer evaluation. CONCLUSION: Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present. Limited evidence is available at this time to guide these treatment strategies.

Critical orthopedic skills and procedures.

Musculoskeletal injury and diseases are common presentations in the Emergency Department. Emergency physicians must be versed in the critical procedural skills necessary to diagnose joint infection, manage fractures and dislocations, and assess for compartment syndrome. Arthrocentesis, splinting, dislocation reduction, and the evaluation of limb compartment syndrome are reviewed.

Etiology of uncompleted exercise stress testing after ED chest pain evaluation.

OBJECTIVE: Emergency department (ED) chest pain protocols often include an exercise stress test (EST) in an outpatient setting to further risk stratify patients initially identified as low risk for acute coronary syndrome. Our goal was to characterize the noncompliant patient population and delineate reasons for uncompleted EST. METHODS: We conducted retrospective chart review of all ED-scheduled ESTs over a 6-month period. Demographic and compliance information was abstracted using standardized instrument, a 1-month consecutive patient subset was identified, and a telephone interview was conducted with noncompliant patients to determine why they did not complete their EST. RESULTS: From January to July 2007, 57% (378/668) of patients were noncompliant with the ED-scheduled EST. In the subset, 78% (78/100) did not complete the EST: 58 patients never showed for their scheduled EST and 20 patients showed but could not initiate the EST because it was deemed inappropriate by health care workers in the cardiovascular laboratory or they began the test and it was nondiagnostic. Noncompliant patients were more likely to be male, unmarried, African American, and uninsured compared to compliant patients (P < .05). The most commonly stated reasons for noncompliance were miscommunication, financial, or inconvenience of scheduled time. Employed patients were more likely to state financial reasons for noncompliance, whereas unemployed patients were more likely to state personal reasons (P < .05). CONCLUSIONS: Our findings suggest lack of patient comprehension about purpose and logistics of EST completion. Based upon our data, the ED should confirm the appropriateness of the EST for each patient and improve patient communication and EST availability.

Care of the bariatric surgery patient in the emergency department.

Obesity has reached epidemic proportions in the United States, with an estimated 50% of adults meeting the definition of being overweight. As this condition has become more prevalent, bariatric surgery has become an increasingly accepted form of treatment of the severely obese. Patients who have had bariatric surgery are presenting more commonly to Emergency Departments as a result. This article will review the most common bariatric surgery procedures, the complications that can arise post-operatively, and the approach to the assessment and management of the bariatric surgery patient in the Emergency Department.