The Chief Wellness Officer: A long overdue catalyst for systemic change in Emergency Medicine.

GOALS: The American healthcare system is amid a burnout epidemic, worsened by COVID, that must be addressed expeditiously and with high priority. The burden Emergency Physicians encountered before and during the pandemic is well known, with countless healthcare workers exiting the work force. A Chief Wellness Officer (CWO) is a senior leader who works primarily to cultivate organisational wellness and to foster and promote a culture of well-being throughout an institution. Specifically, the CWO assists the health system leadership promote clinician engagement and address clinician burnout. This paper explores the status of existing CWOs, and cites the benefits, impacts, and barriers to implementation of a CWO, with focus on the field of Emergency Medicine (EM). METHODS: A steering committee of wellness experts was formed from a national EM organisation. A purposive search and literature review using search terms relating to CWOs was completed. Publications were examined for relevance and recency. The committee created an online questionnaire surveying current US CWOs, conducted personal interviews, and met through regular focused meetings. A framework delineating the role of a CWO as an organisation evolves from instituting novice wellness interventions to expert organisational innovations was created. PRINCIPLE FINDINGS: Despite their title, CWOs are not regularly included in c-suite decisions. Barriers to instituting a CWO include perceived financial cost, the medical system itself, and physician resistance. Defining and measuring objective return on investment may be a solution to overcoming barriers. CWOs who create comprehensive institutional wellness innovations bring organisations to the highest proficient and expert levels of wellness practices, positively affecting physician engagement and deflecting burnout. CWOs instituting novice and beginner levels of wellness interventions, especially in EM, only modestly impact individual wellness practices. PRACTICAL APPLICATIONS: A CWO and team with an organisational voice and a C-suite stakeholder's seat are essential to centralising and leading effective wellness efforts and innovations in EM and other specialities. This team will improve the work environment and culture and begin to fix our broken healthcare system and providers.

Successful Distal Urethral Stone Removal in the Emergency Department.

Nephrolithiasis is a common pathology encountered in the primary care and emergency department (ED) setting. In 2009 alone, there were over one million ED visits related to nephrolithiasis Higa et al. (2017) [1]. Emergent treatment options range from non-invasive pain control and patient education to lithotripsy and other invasive urologic procedures depending on stone location and related pathology. Urethral calculi are estimated to represent 0.3% of all urinary stone diseases Verit et al. (2006) [2]. There are very few case reports documenting distal urethral stone removal in the ED. Here we present a case of distal urethral stone impaction and the removal of this stone by ED providers, leading to expedited care and prevention of consultation and possible admission.

Uterine Artery Pseudoaneurysm: A Life-Threatening Cause of Vaginal Bleeding in the Emergency Department.

BACKGROUND: Vaginal bleeding is a common presenting complaint in the emergency department (ED); life-threatening hemorrhage is rare. Uterine artery pseudoaneurysm (UAP) is an uncommon but potentially life-threatening cause of vaginal bleeding that is most likely to present primarily to EDs, given its delayed postpartum or postoperative presentation. CASE REPORT: A 25-year-old female gravida two, para one, who was 19 days post dilation and evacuation for an elective termination of a pregnancy at 20 weeks, presented to the ED with profuse vaginal bleeding. She was hypotensive and tachycardic at presentation, requiring resuscitation with 0.9% normal saline and transfusions of packed red blood cells. Transvaginal ultrasound completed in the ED demonstrated a pulsatile mass in the cervix with internal "ying-yang" flow on Doppler images, suggestive of a uterine artery pseudoaneurysm within the cervix. The patient underwent emergent uterine artery embolization with resolution of bleeding and improvement in her hemodynamic status. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: UAP is an uncommon cause of vaginal bleeding, but UAP rupture can be life-threatening. UAP is an important differential diagnosis for vaginal bleeding, particularly in the postpartum or postoperative setting. Delaying diagnosis may worsen bleeding in the setting of a ruptured UAP if treatment is pursued for alternative diagnosis; for example, treating retained products of conception with a dilation and curettage. Being aware of UAP and how to diagnose it will allow early proper treatment and more favorable patient outcomes.

Facial Baroparesis Mimicking Stroke.

We report a case of a 55-year-old male who experienced unilateral facial muscle paralysis upon ascent to altitude on a commercial airline flight, with resolution of symptoms shortly after descent. The etiology was determined to be facial nerve barotrauma, or facial baroparesis, which is a known but rarely reported complication of scuba diving, with even fewer cases reported related to aviation. The history and proposed pathogenesis of this unique disease process are described.

Idiopathic Spinal Epidural Lipomatosis Causing Cauda Equina Syndrome.

Spinal epidural lipomatosis (SEL) is a rare condition defined by the hypertrophy of adipose tissue in the spinal epidural space, often resulting in compression of nerves in the region affected.1 This case describes a 64-year-old man who presented with cauda equina syndrome. Magnetic resonance imaging of the spine revealed extensive SEL of the lumbar spine. He underwent decompression and fusion with subsequent improvement of symptoms. This is one of the few cases reported of lumbar SEL in a non-obese patient in absence of long-term corticosteroid usage. We review possible etiologies.

Acute intractable vomiting and severe ketoacidosis secondary to the Dukan Diet©.

BACKGROUND: The benefits of low-carbohydrate, high-protein diets, such as the Dukan Diet©, are well documented, whereas reported adverse effects are rare in literature. Such diets mimic starvation states in that they promote the breakdown of fat and the production of ketones secondary to fatty acid metabolism. In fact, one measure of the effectiveness of such diets is the presence of ketosis. To our knowledge, there have been no reported cases of ketoacidosis resulting from the Dukan Diet. OBJECTIVES: The purpose of this case report is to illustrate the importance of a detailed dietary history in patients with severe ketoacidosis secondary to the Dukan Diet and suggest treatment that may allow outpatient management. CASE REPORT: A 42-year-old Iranian woman with no prior medical problems presented with 10 h of intractable nausea and vomiting secondary to ketoacidosis 2 days after starting the Dukan Diet. CONCLUSION: Although rare, ketoacidosis secondary to a low-carbohydrate, high-protein diet can have serious complications if untreated. Clinical suspicion should arise in any patient presenting with intractable nausea and vomiting after starting a diet such as the Dukan Diet. Early recognition and intervention is essential to quicken patient recovery and outpatient management.

Observational study and estimate of cost savings from use of a health information exchange in an academic emergency department.

BACKGROUND: Federal initiatives to improve health care information sharing have led to the development of a new type of regional electronic medical record known as a health information exchange (HIE). OBJECTIVE: Our aim was to investigate the ability of an HIE to decrease health services use for emergency department (ED) patients. METHODS: We performed an observational, prospective study using a voluntary, anonymous survey among clinicians at an urban academic ED. All ED clinicians were eligible to participate. Survey items addressed clinician perception of whether information from the HIE avoided the use of hospital resources, improved quality of care, and reduced length of stay (LOS). Cost savings were estimated by multiplying the number of services the clinicians completing our survey reported they avoided through use of the HIE by the costs of those services at our facility. The study was approved by the Institutional Review Board at the study site. RESULTS: The study was conducted between August and December of 2011. There were 18,529 patient encounters during the study period and 60 clinicians at the study site who were eligible to participate. The clinicians consulted the HIE for 5.39% of these encounters (998 patients). Surveys were completed by the clinicians caring for 13.8% (n = 138) of these patients. Of the completed surveys, 76% (105 surveys) referenced patients for whom the HIE was found to contain information on the patient under care by the clinician participant. These 105 patients formed the sample on which our analysis was based. Within this sample of patients, the following studies were reported to have been avoided by the clinicians participating in our survey: values are percent of patients for whom a study was reported to have been avoided (actual number of studies avoided): laboratory/microbiology: 30.5% (32 studies); radiologic studies: 47.6% (50 studies); consultations: 19% (20 consultations); and admissions: 11.4% (12 admissions). Calculated cost savings based on these estimates were as follows: laboratory/microbiology: $462.85; radiologic studies: $160,893.00; consultations: $3,990.00; and admissions: $118,131.84. Total savings: $283,477. Clinicians participating in the study reported improved quality of care for 86.7% of their patients, as well as a mean time savings of 120.8 minutes. CONCLUSIONS: According to clinician estimates, use of an HIE in this urban academic ED resulted in reduced use of hospital resources, noteworthy cost savings, decreased LOS, and improved quality of care. Limitations included the observational nature of the study, selection bias, the Hawthorne effect, and cost estimates being from a single institution. Allowance was not made for additional services used because of information obtained from the HIE.

Renal abscess in a patient presenting with persistent hiccups.

Hiccups are common, typically limited, and rarely present with adverse complications. In the context of persistent or intractable episodes, however, hiccups may signal a more serious underlying cause. Here, we present an unexpected and pathologic case of hiccups in a patient who was ultimately diagnosed with renal abscesses.

Gastric rupture from cardiopulmonary resuscitation or seizure activity? A case report.

Ascertaining the cause of a gastric rupture is difficult and can be complicated by events occurring in the pre-hospital phase of patient care. To our knowledge, only seven cases of cardiopulmonary resuscitation (CPR)-related injuries to the stomach have been reported in the literature since 1997. We found no reports of seizure-related gastric injury. We present the case of a patient who sustained a gastric rupture, tension pneumoperitoneum, and a tension pneumomediastinum after retching, seizure, CPR, and advanced cardiac life support maneuvers.

Detection of Loxosceles species venom in dermal lesions: a comparison of 4 venom recovery methods.

STUDY OBJECTIVE: Loxosceles species spider envenomations may produce necrotic, disfiguring dermal inflammatory lesions resembling neutrophilic dermatoses. With definitive treatment options lacking, clinicians are reluctant to obtain invasive biopsy specimens for diagnostic analysis. We compared less invasive venom collection methods and determined the time limit after inoculation for feasible venom recovery in an animal model. METHODS: Nine New Zealand rabbits were randomized to 1 of 3 groups (n=3). Groups 1 and 2 were inoculated intradermally with 3 microg of L reclusa venom at 5 inoculation sites per rabbit. Albumin (3 microg) was injected intradermally in each rabbit as a negative control. Hair (group 1) and aspirate samples (group 2) were collected (1 time per site) over a 1-week period after inoculation. Group 3 was inoculated with 3 microg of Loxosceles species venom on 1 flank and 3 microg of albumin on the opposite flank. Daily serum specimens were collected over a 7-day period. On day 7, dermal punch biopsy specimens were taken from the venom and control inoculation sites. Hair, aspirate, biopsy, and serum specimens were assayed for venom by using an enzyme-linked immunosorbent assay. A generalized linear model was fit with the generalized estimating equation method to estimate the mean differences between groups. RESULTS: Venom was detected in hair, aspirate, and biopsy specimens on all days of the study period. Hair samples yielded venom recovery on day 1 (median 0.062 ng/100 microL; mean difference 0.054 ng/100 microL; 95% confidence interval [CI] 0.048 to 0.059) through day 7 (median 0.020 ng/100 microL; mean difference 0.020 ng/100 microL; 95% CI 0.013 to 0.027). Aspirates were positive for venom recovery on day 1 (median 0.275 ng/100 microL; mean difference 0.231 ng/100 microL; 95% CI 0.192 to 0.271) through day 7 (median 0.0 ng/100 microL; mean difference 0.032 ng/100 microL; 95% CI -0.18 to 0.078). The highest venom yield was from the biopsy specimens (median 1.75 ng/100 microL; mean difference 0.041 ng/100 microL; 95% CI 0.033 to 0.027). Venom was undetectable in all serum samples. CONCLUSION: Loxosceles species venom is detectable in hair, aspirate, and dermal biopsy specimens at least 7 days after venom inoculation and undetectable in serum by using the rabbit model.

A new assay for the detection of Loxosceles species (brown recluse) spider venom.

STUDY OBJECTIVE: Dermal lesions from unrelated arthropod species and medical causes appear similar to Loxosceles species (brown recluse spider) bites. This may result in delayed diagnosis and treatment. We developed a sensitive Loxosceles species venom enzyme-linked immunosorbent assay (ELISA) and characterized the specificity of the assay by evaluating antigenic cross-reactivity from a variety of North American arthropod venoms. METHODS: North American arthropod (14 spiders, 2 scorpions, and 1 bee) venoms were studied. Three venom amounts (diluted in 100 microL of ELISA buffer) were assayed: 16,000 ng, 2,000 ng, and 40 ng. The latter quantity was selected because this is the observed maximum amount of venom we detect when inoculating dermis with amounts likely to be deposited by a spider bite. The larger venom amounts are overwhelming quantities designed to test the limits of the assay for arthropod venom cross-reactivity. Similar amounts of Loxosceles species venom and bovine albumin served as positive and negative controls, respectively. RESULTS: At the lowest amount of venom tested (40 ng), the ELISA detected only the Loxosceles species positive control. When 2,000 ng was assayed, only Scytodes fusca and Kukulcania hibernalis arachnid venoms (in addition to Loxosceles species) cross-reacted to the assay. Finally, at 16,000 ng, the ELISA assay modestly detected Diguetia canities, Heteropoda venatoria, Tegenaria agrestis, Plectreurys tristes, Dolomedes tenebrosus, and Hadrurus arizonensis arachnid venoms. CONCLUSION: Cross-reactivity was observed in 8 of 17 North American arthropod venoms when large venom amounts were assayed with a Loxosceles species ELISA. By using a relevant quantity of venom, 40 ng, the assay was specific for Loxosceles species venom. The venom specificity of the ELISA may allow clinical application in Loxosceles species endemic regions of North America.