Emergency Department Adaptations to COVID-19.

BACKGROUND: The COVID-19 pandemic creates unique challenges for healthcare systems. While mass casualty protocols and plans exist for trauma-induced large-scale resource utilization events, contagious infectious disease mass casualty events do not have such rigorous procedures established. COVID-19 forces Emergency Departments (EDs) to simultaneously treat seriously ill patients and evaluate large influxes of 'worried well'-while maintaining both staff and patient safety. METHODS: The objectives of this project are to create an avenue to evaluate large surges of patients while minimizing hospital-acquired infections. After identifying areas for improvement and anticipating potential failures, we devised eight healthcare delivery innovations to address those areas and meet our objectives: (1) Parallel ED Lanes (2) Universal Respiratory Precautions (3) Respiratory Drive Through (RDT) (4) Medical Company (5) Provider Triage (6) ED Quarterback Patient Liaison (EDQB) (7) Virtual Registration (8) Virtual Ward. RESULTS: To date, no staff members have contracted COVID-19 within the ED footprint. Our RDT has seen 16,994 patients and the medical company 1,109. Provider triage has redirected 465 patients, while our EDQB has interacted with 532 and redirected 93 patients for same-day appointments with their Primary Care Manager (PCM). CONCLUSION: The system of care establish at our Military Treatment Facility (MTF) has been effective in maximizing staff and patient safety, while providing a new patient-centered healthcare delivery apparatus.

Low Incidence of Death and Renal Failure in United States Military Service Members Hospitalized with Exertional Heat Stroke: A Retrospective Cohort Study.

INTRODUCTION: The goal of the current study was to characterize the rate and estimate associated mortality and morbidity of exertional heat stroke (EHS) in U.S. military service members. MATERIALS AND METHODS: The current study was a retrospective cohort medical chart review study of all active-duty U.S. military service members, hospitalized with EHS at any MTF in the world between January1, 2007 and July 1, 2014. Enrolled patients were identified by altered mental status and elevated temperatures associated with physical exercise. RESULTS: Out of 607 service members with an International Classification of Disease code indicating any type of heat injury, 48 service members met inclusion criteria for EHS. Core temperature was M = 105.8°F (41°C), standard deviation = 1.43, 90% were diagnosed with EHS prior to hospitalization, and 71% received prehospital cooling. Meantime to normothermia post-hospitalization was 56 minutes (standard deviation = 79.28). Acute kidney injury was diagnosed in 40% of patients although none developed hyperkalemia or required dialysis. Disseminated intravascular coagulation was rare (4%, n = 2) and overall observed mortality was very low (2%, n = 1). CONCLUSION: EHS is aggressively identified and treated in U.S. Military Treatment Facilities. Mortality and morbidity were strikingly low.

Community hospital experience in the emergency management of COVID-19: Preventing morbidity and preserving resources.

An incredible amount of information has been published regarding inpatient management of patients with COVID-19. Although this is vitally important, critical interventions that occur in the emergency department (ED) can have a profound impact on the individual patient and the healthcare system as a whole.  Much has been written regarding care in large centers, but there has been little discussion regarding similar patients in community settings. Prior to the pandemic, large centers were able to accept patients that outstripped the resources in community hospital settings, but currently we foresee that many community centers will begin to manage more complex cases without referral. As physicians in a medium-sized community academic center, we aim to enumerate community-hospital-relevant guidance for ED care that focuses on adherence to available evidence-based medicine, including early aggressive supplemental oxygenation, awake proning, and methods to improve oxygenation and ultimately delay intubation as long as safely possible.  Equally importantly, it was recognized early that adjustments to medication regimens (eg, sedation) and personal protective equipment (PPE) use must be made in the ED to conserve those same resources for long-term use in inpatient units and improve the functionality of the hospital system as a whole. It is our hope that this article may serve as a framework for similar community-based hospitals to create their own protocols to optimize resource utilization, staff safety, and patient care.

Injuries Sustained During Modern Army Combatives Tournaments.

INTRODUCTION: Injuries sustained during Modern Army Combatives (MAC) tournaments can result in variable recovery time for involved competitors and unpredictable loss of readiness for military units. A paucity of MAC data is available to guide military medical providers and unit commanders on expected injuries or loss of readiness. Literature reviewing mixed martial arts competitions offers some insight but demonstrates variation in fight outcomes resulting in injuries ranging from 8.5% to 70% and it is difficult to effectively extrapolate such data to predict MAC tournament injuries. MATERIALS AND METHODS: This study retrospectively reviews pre- and post-competition medical records from two MAC tournaments held at Fort Hood in 2014 and 2015 to provide descriptive clinical information on injury patterns to practitioners and military commanders. RESULTS: Records from a total of 195 competitors with a mean age of 24.4 yr were analyzed with a total of 67 injuries, 29 of which resulted in duty limitations (14.8% of participants). Competitors participating in less-restrictive mixed martial arts style fighting (Advanced MAC) were 4.3 times more likely to sustain an injury than those limited to upper body grappling events (95% confidence interval 2.30-8.16). Military Acute Concussion Evaluations were reliably recorded both pre- and post-competition in 44% of total participants with no significant statistical difference between pre- and post-tournament evaluations. Duty profile limitations of injured competitors averaged 1 mo in duration. CONCLUSIONS: MAC tournaments result in injury rates comparable with other combative sports and military training courses.

Ultrasound Versus Landmarks for Great Toe Arthrocentesis.

BACKGROUND: Several studies have demonstrated ultrasound (US) is superior to traditional landmark (LM)-based techniques for large and medium joint aspiration; however, no studies of sufficient size have evaluated these interventions in the smaller toe joints. The purpose of this study was to determine if US provides an advantage over LM for successful first-pass aspiration of first metatarsophalangeal joint (1st MTPJ) effusions. METHODS: A cross-over, cadaveric trial evaluating the interventions of US and LM. Eighteen emergency medicine residents performed four US and four LM aspirations each of 1st MTPJ effusions simulated in fresh-frozen cadavers. The initial intervention utilized was randomized. The primary outcome measured was aspiration success or failure. A secondary outcome measured was time in seconds taken to complete a successful aspiration. RESULTS: A total of 144 1st MTPJ aspirations were attempted-72 by US and 72 by LM. US was the initial intervention used in 9 of 18 (50%) participants. Fifty-seven of 72 (79.2%) US attempts were successful, while 53 of 72 (73.6%) LM attempts were successful (95% confidence interval 69.5%, 83.3%; p = 0.56). Successful US aspirations took 43.7 seconds (±31.0), whereas successful LM aspirations averaged 34.0 seconds (±24.3). The mean difference in time to successful aspiration was 9.7 seconds (95% confidence interval 20.3, -0.9; p = 0.07). There was no statistically significant difference in success and time between US and LM. CONCLUSION: In this study, US did not prove superior to LM for first-pass aspiration of 1st MTPJ effusions.

Acetazolamide 125 mg BD is not significantly different from 375 mg BD in the prevention of acute mountain sickness: the prophylactic acetazolamide dosage comparison for efficacy (PACE) trial.

750 mg per day of acetazolamide in the prevention of acute mountain sickness (AMS), as recommended in the meta-analysis published in 2000 in the British Medical Journal, may be excessive and is controversial. To determine if the efficacy of low-dose acetazolamide 125 mg bd (250 mg), as currently used in the Himalayas, is significantly different from 375 mg bd (750 mg) of acetazolamide in the prevention of AMS, we designed a prospective, double-blind, randomized, placebo-controlled trial. The participants were sampled from a diverse population of (non-Nepali) trekkers at Namche Bazaar (3440 m) in Nepal on the Everest trekking route as they ascended to study midpoints (4280 m/4358 m) and the endpoint, Lobuje (4928 m), where data were collected. Participants were randomly assigned to receive 375 mg bd of acetazolamide (82 participants), 125 mg bd of acetazolamide (74 participants), or a placebo (66 participants), beginning at 3440 m for up to 6 days as they ascended to 4928 m. The results revealed that composite AMS incidence for 125 mg bd was similar to the incidence for 375 mg bd (24% vs. 21%, 95% confidence interval, -12.6%, 19.8%), in contrast to significantly greater AMS (51%) observed in the placebo group (95% confidence interval for differences: 8%, 46%; 12%, 49% for low and high comparisons, respectively). Both doses of acetazolamide improved oxygenation equally (82.9% for 250 mg daily and 82.8% for 750 mg daily), while placebo endpoint oxygen saturation was significantly less at 80.7% (95% confidence interval for differences: 0.5%, 3.9% and 0.4%, 3.7% for low and high comparisons, respectively). There was also more paresthesia in the 375-mg bd group (p < 0.02). We conclude that 125 mg bd of acetazolamide is not significantly different from 375 mg bd in the prevention of AMS; 125 mg bd should be considered the preferred dosage when indicated for persons ascending to altitudes above 2500 m.