Cheiro-Oral syndrome.

The Cheiro-Oral (COS) Syndrome is a rare neurologic condition characterized by sensory disturbances involving the peri-oral area and the upper extremity, typically isolated to the hand or fingers. The thalamus contralateral to the symptomatic side is the brain region most commonly involved. Most cases are caused by ischemic or hemorrhagic strokes, although other structural lesions have been implicated. These include tumors, subdural hematomas, aneurysms, and infections. The unusual and seemingly unrelated nature of the symptoms may contribute to misdiagnosis and incomplete workup for potentially serious conditions. We are unable to identify a report of this condition in the emergency medicine literature despite the emergency department being the likely point of presentation for patients with COS. In this report, we describe two patients with COS who presented to our emergency department and review the features of COS as described in published case reports.

Dashboard visualizations: Supporting real-time throughput decision-making.

Providing timely and effective care in the emergency department (ED) requires the management of individual patients as well as the flow and demands of the entire department. Strategic changes to work processes, such as adding a flow coordination nurse or a physician in triage, have demonstrated improvements in throughput times. However, such global strategic changes do not address the real-time, often opportunistic workflow decisions of individual clinicians in the ED. We believe that real-time representation of the status of the entire emergency department and each patient within it through information visualizations will better support clinical decision-making in-the-moment and provide for rapid intervention to improve ED flow. This notion is based on previous work where we found that clinicians' workflow decisions were often based on an in-the-moment local perspective, rather than a global perspective. Here, we discuss the challenges of designing and implementing visualizations for ED through a discussion of the development of our prototype Throughput Dashboard and the potential it holds for supporting real-time decision-making.

A comparison of two techniques for tungsten carbide ring removal.

INTRODUCTION: Emergency physicians may have difficulty removing modern rings made of hard metals such as titanium and tungsten carbide. These metals are exceptionally difficult or impossible to remove using standard ring cutters. Numerous alternative techniques for removal have been described, including the "umbilical tape" or "string technique" and, in the case of tungsten carbide, breaking the ring using locking pliers. OBJECTIVE: We sought to compare the speed and effectiveness of tungsten carbide ring removal using these two techniques. METHODS: Ten tungsten carbide rings were placed upon the finger of a standard medical simulation mannequin. The rings chosen were one-half size smaller than the mannequin's finger. Edema distal to the ring was simulated using foam tape. A single novice operator performed 10 trials using each of the techniques after a 10-minute orientation session. The success or failure of the technique and the time for removal were recorded for each trial. The mean removal times for the trials were compared using a paired t test. RESULTS: All trials were successful. The rings were removed substantially faster using the locking pliers method (mean 23.1 seconds [95% CI 15.4-30.8] vs. mean 135.4 seconds [95% CI 130.2-150.6]). However, the locking pliers technique destroyed all rings and caused sharp ring fragments to be thrown up to 37 in. CONCLUSIONS: Both the umbilical tape or string technique and the locking pliers technique successfully removed tungsten carbide rings in our model. The locking pliers technique is significantly faster but destroys the ring and creates potentially harmful shrapnel.

Scholarship in emergency medicine in an environment of increasing clinical demand: proceedings from the 2007 Association of American Medical Colleges annual meeting.

Academic emergency medicine can benefit by broadening the way in which scholarship is defined to include teaching, integration of knowledge, application of knowledge to practical clinical problems and as discovery of new knowledge. A broad view of scholarship will help foster innovation and may lead to new areas of expertise. The creation of a scholarly environment in emergency medicine faces the continued challenge of an increasing clinical demand. The solution to this dilemma will likely require a mix of clinical staff physicians and academic faculty who are appreciated, nurtured and rewarded in different ways, for the unique contributions they make to the overall success of the academic program.

Pediatric and neonatal transport teams with and without a physician: a comparison of outcomes and interventions.

OBJECTIVE: To determine whether a transport team composed of advanced practice nurses could function as effectively as a physician-nurse team, as measured by patient outcome. DESIGN: Observational cohort study. SETTING: The interfacility transport team at a tertiary care children's hospital. PATIENTS AND OTHER PARTICIPANTS: Fourteen transport nurses and 539 patients. METHODS: A transport team was studied during a previously planned change in composition from a physician-nurse team to a nurse-nurse team. Data were recorded by transport nurses and by subsequent review of the medical record during two 4-month periods, 1 before and 1 after the team change. Pediatric risk of mortality scores (a marker for degree of illness) were assigned for the periods before, during, and after transport. Transport time intervals, demographic data, and patient outcomes were also recorded. Data were assessed using frequency tables for discrete variables, as well as mean and standard deviation for continuous variables. For identification of group differences, chi test was used. MAIN OUTCOME MEASURES: Mortality, transport-related morbidity, overall transport times and interval times, and outcome of procedures performed by transport nurses. RESULTS: Five hundred thirty-nine data sheets were received: 228 before (group 1) and 311 after (group 2) the team change. Physicians attended 128 (56.1%) group 1 transports and 15 (4.82%) group 2 transports. There were no significant differences in mean pediatric risk of mortality scores between group 1 and group 2 patients. Mortality was equivalent. Group 2 transport times were significantly shorter than group 1 times. Transport nurses performed 8 intubations; all were successful. CONCLUSIONS: Outcomes for the 2 types of teams were equivalent. Nonphysician teams responded more quickly and spent less time at the referring facility.

Pediatric critical care transport--the safety of the journey: a five-year review of vehicular collisions involving pediatric and neonatal transport teams.

OBJECTIVE: To determine the frequency and consequences of vehicular crashes among dedicated pediatric and neonatal transport teams. METHODS: A three-page questionnaire was sent to the transport teams of National Association of Children's Hospitals and Related Institutions (NACHRI) member hospitals. The survey instrument consisted of three sections. The first section requested demographic information about the team and asked the team to report any vehicular collisions or incidents in the previous five years. The second section was directed at teams that did not report collisions or incidents and asked the team to identify potential reasons for their safety record. The third section was directed to those teams reporting collisions or incidents and asked about the causes and consequences of these events. RESULTS: Ninety of 153 (59%) surveys were returned. Thirty-eight of the 90 teams (42%) reported at least one collision in the previous five years. A total of 66 collisions were reported (nine aircraft crashes and 57 ambulance collisions). The number of collisions was not related to the total number of transports performed by the team. Most teams attributed the collisions to errors on the part of a team member or to the actions of a third party. Collisions resulted in eight deaths, ten cases of moderate to severe injury, and 28 minor injuries to patients, health care workers, and/or the ambulance crew. All deaths resulted from aircraft crashes. Additionally, there were operational impacts upon the teams. These included missed workdays and disability on the part of team members and changes in team practices. Collision-free teams attributed their safety record to specific policies of the team and/or the vehicle owner or vendor and to luck. CONCLUSIONS: Collisions/crashes among pediatric transport teams are unusual. However, they have resulted in deaths, injuries, and disability. Collisions/crashes appear to be caused by the actions of a team member and/or those of third parties. Specific safety policies on the part of the team and/or vehicle owner or provider may prevent or decrease collisions/crashes.

Self-administered decision support tool for triage: results of a retrospective study.

BACKGROUND: This study was designed to evaluate the safety of a self-administered triage tool. MATERIALS: Ninety-five patients older than 14 years who presented to Memorial Hermann Hospital emergency room (ER) with chief complaint of abdominal pain were included in the study. Their ER disposition and final diagnoses were logged into a database. The assigned disposition and top three diagnoses by the triage tool for each patient were also logged into the database. An emergency physician blinded to the actual disposition reviewed all cases and provided a disposition for each patient. RESULTS: The system disposed 51.1% of cases appropriately and under-disposed 4.4% of cases. Comparison between the system and the emergency physician shows that all cases under-disposed by the system are also under-disposed by the physician.