A case of sudden, painless, and persistent urinary incontinence.

BACKGROUND: Urinary incontinence is not a common emergency department (ED) complaint, and it is hard to imagine that a case involving this complaint could turn out to be interesting. We report the case of a patient who presented with the complaint of sudden onset of painless urinary incontinence for 1 day, who had an unexpected diagnosis. OBJECTIVES: To describe a case of incontinence with an unexpected diagnosis and to review the various causes of incontinence. CASE REPORT: A 52-year-old woman with a history of kidney stones recently treated with lithotripsy, nephrostomy tubes, and ureteral stents, presented to the ED complaining of new-onset incontinence. The patient had awakened on the morning of presentation with urinary incontinence that persisted throughout the day. On examination she had normal vital signs, and other than a functioning nephrostomy tube, she had a normal examination. In addition to a urinalysis, a KUB (kidney, ureter, and bladder) X-ray study was performed, which showed that her recently placed right ureteral stent had migrated from its original location into the urethra. The stent was found by the urologist protruding from the urethral meatus and removed without difficulty. The patient's incontinence resolved immediately after the stent was removed. CONCLUSION: Emergency physicians frequently see patients with ureteral stents, but may not be aware of how frequently those stents can migrate or malfunction. Our experience suggests that radiologic determination of stent location may be helpful in patients who present with new-onset stress or overflow incontinence.

Indian and United States paramedic students: comparison of examination performance for the American Heart Association Advanced Cardiovascular Life Support (ACLS) training.

BACKGROUND: The American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) course is taught worldwide. The ACLS course is designed for consistency, regardless of location; to our knowledge, no previous study has compared the cognitive performance of international ACLS students to those in the United States (US). STUDY OBJECTIVES: As international health educational initiatives continue to expand, an assessment of their efficacy is essential. This study assesses the AHA ACLS curriculum in an international setting by comparing performance of a cohort of US and Indian paramedic students. METHODS: First-year paramedic students at the Emergency Management and Research Institute, Hyderabad, India, and a cohort of first-year paramedic students from the United States comprised the study population. All study participants had successfully completed the standard 2-day ACLS course, taught in English. Each student was given a 40-question standardized AHA multiple-choice examination. Examination performance was calculated and compared for statistical significance. RESULTS: There were 117 Indian paramedic students and 43 US paramedic students enrolled in the study. The average score was 86% (± 11%) for the Indian students and 87% (± 6%) for the US students. The difference between the average examination scores was not statistically significant in an independent means t-test (p=0.508) and a Wilcoxon test (p=0.242). CONCLUSION: Indian paramedic students demonstrated excellent ACLS cognitive comprehension and performed at a level equivalent to their US counterparts on an AHA ACLS written examination. Based on the study results, the AHA ACLS course proved effective in an international setting despite being taught in a non-native language.

Thunderclap headache with orgasm: a case of basilar artery dissection associated with sexual intercourse.

BACKGROUND: Headaches associated with sexual intercourse (coital cephalgia) have many different causes and are often divided in the literature into pre-orgasmic and orgasmic headaches. OBJECTIVE: To present a case of orgasmic headache caused by a basilar artery dissection and to present a literature-based guide to the diagnosis and management of patients presenting with headaches related to sexual activity. CASE REPORT: We report the case of a 34-year-old man without significant past medical history who presented to the Emergency Department with two episodes of orgasmic headache caused by basilar artery dissection. CONCLUSIONS: The cause of headaches related to sexual activity range from the benign to the life-threatening. Due to the dynamics of cerebral blood flow during sexual intercourse, basilar artery dissections and aneurysms should be considered in patients with sudden-onset headaches during orgasm. Appropriate brain imaging and, possibly, lumbar puncture may assist in identifying potentially life-threatening causes of coital headaches.

Serious infectious complications related to extremity cast/splint placement in children.

BACKGROUND: Extremity injuries necessitating splinting or casting are commonly seen in the emergency department (ED) setting. Subsequently, it is not uncommon for patients to present to the ED with complaints related to an extremity cast or splint. OBJECTIVE: To present a literature-based approach to the identification and initial management of patients with possible infectious cast/splint complications in the ED setting. CASE REPORTS: We present two cases of serious infectious complications arising from extremity cast/splint placement seen in a single pediatric ED: a case of toxic shock syndrome in an 8-year-old child, and a case of necrotizing fasciitis resulting in upper extremity amputation in a 3-year-old child. CONCLUSIONS/SUMMARY: A wide spectrum of potential extremity cast/splint infectious complications may be seen, which include limb- or life-threatening infections such as toxic shock syndrome and necrotizing fasciitis. Simply considering these diagnoses, and removing the cast or splint to carefully inspect the affected extremity, are potential keys to early identification and optimal outcome of cast/splint complications. It is also prudent to maintain particular vigilance when treating a patient with a water-exposed cast, which may lead to moist padding, skin breakdown, and potential infection. In patients with suspected serious infections, aggressive fluid management and antibiotic therapy should be initiated and appropriate surgical consultation obtained without delay.

Evaluating the efficacy of simulators and multimedia for refreshing ACLS skills in India.

OBJECTIVE: Data on the efficacy of the simulation and multimedia teaching modalities is limited, particularly in developing nations. This study evaluates the effectiveness of simulator and multimedia educational tools in India. METHODS: Advanced Cardiac Life Support (ACLS) certified paramedic students in India were randomized to either Simulation, Multimedia, or Reading for a 3-h ACLS refresher course. Simulation students received a lecture and 10 simulator cases. The Multimedia group viewed the American Heart Association (AHA) ACLS video and played a computer game. The Reading group independently read with an instructor present. Students were tested prior to (pre-test), immediately after (post-test), and 3 weeks after (short-term retention test), their intervention. During each testing stage subjects completed a cognitive, multiple-choice test and two cardiac arrest scenarios. Changes in exam performance were analyzed for significance. A survey was conducted asking students' perceptions of their assigned modality. RESULTS: One hundred and seventeen students were randomized to Simulation (n=39), Multimedia (n=38), and Reading (n=40). Simulation demonstrated greater improvement managing cardiac arrest scenarios compared to both Multimedia and Reading on the post-test (9% versus 5% and 2%, respectively, p<0.05) and Reading on the short-term retention test (6% versus -1%, p<0.05). Multimedia showed significant improvement on cognitive, short-term retention testing compared to Simulation and Reading (5% versus 0% and 0%, respectively, p<0.05). On the survey, 95% of Simulation and 84% of Multimedia indicated they enjoyed their modality. CONCLUSION: Simulation and multimedia educational tools were effective and may provide significant additive benefit compared to reading alone. Indian students enjoyed learning via these modalities.