The seven day itch: A delayed histamine reaction to stingray injury.

Stingray injuries are common presentations to emergency departments near warm coastal waters. Commonly reported injuries include puncture wounds, lacerations, and envenomations, the latter of which cause severe pain but are usually easily treated with warm water immersion. We report a case of delayed histamine reaction in a patient who sustained a stingray envenomation one week prior which we believe is the first such report in the medical literature but is found on discussion boards for those who have sustained stingray injuries. The literature on such envenomations is reviewed.

Prevalence and correlates of spitting on police officers: New risks in the COVID era.

OBJECTIVES: Spitting is an occupational hazard of police work with increased risk due to the COVID-19 pandemic. We sought to calculate the prevalence of spitting on police officers in use of force incidents, as well as the demographic and situational factors associated with spitting. METHODS: Data on spitting were compiled from more than 10,000 use of force incidents occurring at 81 agencies in eight different states in the US. RESULTS: Spitting occurred in 3.6% of cases. Female and younger subjects and those using drugs and/or alcohol are more likely to spit on officers. Spitting is more likely to occur in incidents of longer duration, when officers use less force relative to subject resistance, when subjects are assaultive or engage in self-harm, and when subjects are hobbled. CONCLUSIONS: Spitting on officers is common and may now constitute a significant work hazard. Implications for police practice are discussed.

Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology.

OBJECTIVES: Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients. METHODS: From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause. RESULTS: SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. CONCLUSIONS: This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

A Novel Medical Student Assistant Accommodation Model for a Medical Student With a Disability During a Required Clinical Clerkship.

BACKGROUND: As efforts continue to diversify the physician workforce so that it better matches the patient population, the number of medical students with disabilities will increase. U.S. medical schools and emergency medicine (EM) clerkships should be prepared to provide full and meaningful access to learners with disabilities. METHODS: We created a novel means of providing access to a senior medical student with a mobility disability (secondary to a cervical spinal cord injury) to participate in a fourth-year EM clerkship. We hired four second-year medical students as intermediaries to perform senior medical student-directed physical examination maneuvers, during his 15 required 8-hour emergency department shifts. The senior medical student dictated his documentation using Dragon Natural Speaking (Nuance Communications, 2015) voice recognition software. RESULTS: The senior medical student successfully completed the required clinical clerkship and earned a honors grade for his work. Both the senior medical student and the second-year medical student intermediaries gave positive feedback about the experience. CONCLUSIONS: Given the significant prevalence of disability among medical students in U.S. medical schools, medical educators should provide greater access to students with disabilities and opportunities for advanced education for all learners by creating innovative clinical curriculum. The authors recommend the student intermediary model for senior medical students with physical disabilities in required clinical clerkships.

Diagnostic accuracy of early computed tomographic coronary angiography to detect coronary artery disease after out-of-hospital circulatory arrest.

AIM: To test the diagnostic accuracy of ECG-gated coronary computed tomography angiography (CCTA) to detect coronary artery disease (CAD) among survivors of out-of-hospital circulatory arrest (OHCA). METHODS: We prospectively studied head-to-pelvis computed tomography (CT) scanning (<6 h from hospital arrival) in OHCA survivors. This sub-study tested the primary outcome of CCTA diagnostic accuracy to identify obstructive CAD (≥50% stenosis) compared to clinically-ordered invasive coronary angiography. Patients were not optimized with beta receptor blockade or nitroglycerin. Secondary analyses included CCTA accuracy for CAD in major coronary arteries, obstructive disease at ≥70% stenosis threshold, and where non-evaluable CCTA segments were considered either obstructive or non-obstructive. RESULTS: Of the 104 enrolled OHCA survivors, 28 (27%) received both CT and invasive angiography in this sub study. All CCTA studies were evaluable although 49/346 (14%) individual coronary segments were unevaluable, primarily due to being too small to evaluate (65%). Patient-level diagnostic accuracy for the ≥50% stenosis threshold was high at 0.93 (95% CI 0.77-0.98) with a specificity of 1.0 (95% CI 0.8-1.0), sensitivity of 0.85 (95%CI 0.58-0.96), negative predictive value of 0.88 (95% CI 0.66-0.97) and positive predictive value of 1.0 (0.74-1.0). When non-evaluable segments were considered obstructive, the sensitivity rose to 0.92 (95% CI 0.67-0.99) with lower specificity of 0.27 (95% CI 0.11-0.52). CONCLUSION: Early CCTA of OHCA survivors has high diagnostic accuracy to detect obstructive coronary artery disease. However, the number of non-diagnostic coronary segments is high suggesting further CCTA refinement is needed, such as the pre-CCTA use of nitroglycerin. CLINICAL TRIAL REGISTRATION: NCT03111043 https://clinicaltrials.gov/ct2/show/record/NCT03111043.

The Relationship of Injury and Complaints of Police Use of Excessive Force.

Use of excessive force (UOEF) is an important and controversial topic but little is known about how injury severity is related to allegations of UOEF. We hypothesized that such complaints would be associated with more significant traumatic injuries. Emergency department records were searched for all individuals making UOEF complaints against an urban police department from 2010 to 2012. Demographic, diagnosis, and other medical data, including Injury Severity Score, were obtained. From police records, force used, suspect resistance and threat, and other call data were obtained. The same data were collected for a control group randomly chosen from all use-of-force events identified during the study period. Of the 235 complaints filed, 42 (18%) subjects had medical evaluation. The control group was significantly younger and more likely to be male; there was no significant difference in race or income. Major injuries were infrequent. No significant difference was found in Injury Severity Score or other medical variables between the 2 groups. Among the law enforcement variables, the only significant difference was a higher likelihood of psychiatric-related calls in the control group. The majority of patients alleging UOEF did not require immediate medical attention, and we found no relationship between injury severity and UOEF complaints.

Navigating Cognitive Dissonance: A Qualitative Content Analysis Exploring Medical Students' Experiences of Moral Distress in the Emergency Department.

BACKGROUND: As undergraduate medical students are acculturated into clinical practice, they develop a set of refined professional values that impact their decision making. We aimed to use students' reflective narratives on ethical dilemmas to identify how students experience moral distress while working in the emergency department (ED) to better understand how to support them in the development of their own agency to act ethically. METHODS: Students rotating in our emergency medicine clerkship are required to submit an essay describing an ethical dilemma they encountered. We selected a random sample of these reflective pieces from the 2015 and 2016 academic years and used an exploratory qualitative thematic analytic approach to identify frequently recurring themes. This process was continued until thematic sufficiency was reached. RESULTS: Two-hundred essays were coded, and seven unique themes were identified. The moral distress students described in reflective writing narratives stemmed from patient-provider discord, uncertainty, and social injustices. In each case, students were expressing the cognitive dissonance they experienced as they began to reconcile the difference between their perceptions of optimal patient care and the actual care delivered to the patient. CONCLUSION: Understanding medical students' cognitive dissonance in the ED will help educators support their students as they negotiate the differences between preferences and principles while being acculturated into clinical practice. Future work should develop specific interventions to promote educator understanding of learners' moral distress and to develop novel models of support for learners.

Does the Medium Matter? Evaluating the Depth of Reflective Writing by Medical Students on Social Media Compared to the Traditional Private Essay Using the REFLECT Rubric.

INTRODUCTION: Social media is a novel medium to host reflective writing (RW) essays, yet its impact on depth of students' reflection is unknown. Shifting reflection on to social platforms offers opportunities for students to engage with their community, yet may leave them feeling vulnerable and less willing to reflect deeply. Using sociomateriality as a conceptual framework, we aimed to compare the depth of reflection in RW samples submitted by medical students in a traditional private essay format to those posted on a secure social media platform. METHODS: Fourth-year medical students submitted a RW essay as part of their emergency medicine clerkship, either in a private essay format (academic year [AY] 2015) or onto a closed, password-protected social media website (AY 2016). Five raters used the Reflection Evaluation for Learners' Enhanced Competencies Tool (REFLECT) to score 122 de-identified RW samples (55 private, 67 social media). Average scores on two platforms were compared. Students were also surveyed regarding their comfort with the social media experience. RESULTS: There were no differences in average composite REFLECT scores between the private essay (14.1, 95% confidence interval [CI], 12.0-16.2) and social media (13.7 95% CI, 11.4-16.0) submission formats (t [1,120] = 0.94, p = 0.35). Of the 73% of students who responded to the survey, 72% reported feeling comfortable sharing their personal reflections with peers, and 84% felt comfortable commenting on peers' writing. CONCLUSION: Students generally felt comfortable using social media for shared reflection. The depth of reflection in RW essays was similar between the private and social media submission formats.

Diagnostic yield of non-invasive imaging in patients following non-traumatic out-of-hospital sudden cardiac arrest: A systematic review.

AIM: To review data for non-invasive imaging in the diagnosis of non-traumatic out-of-hospital cardiac arrest (OHCA). DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane library, and clinicaltrials.gov databases from inception to January 2017 for studies utilizing non-invasive imaging to identify potential causes of OHCA [computed tomography (CT), ultrasound including echocardiography, and magnetic resonance (MRI)]. STUDY SELECTION: Inclusion criteria were the following: (1) randomized control trials, cohort studies or observational studies; (2) contained a population ≥18 years old with non-traumatic OHCA who underwent diagnostic imaging with CT, MRI, echocardiography, or abdominal ultrasound; (3) imaging was obtained for diagnostic purposes; (4) patients were alive or were undergoing cardiopulmonary resuscitation at the time of imaging; (5) contained potential causes of OHCA. Endpoints studied were the number of potential OHCA causes identified, diagnostic accuracy measures (sensitivity, specificity, positive and negative predictive values), and diagnostic utility (number of imaging findings with reported changes in clinical management). RESULTS: Of the total 5722 studies identified, 17 (0.3%) met inclusion criteria. The majority of studies assessed the utility of CT in OHCA (n=10), and potential causes of OHCA were found in 8-54% of patients following head, abdominal and/or chest CT. Only 1/17 (6%) studies reported diagnostic accuracy measures, and 9/17 (53%) studies included a time to imaging criteria within 24h. CONCLUSION: Although non-invasive imaging is commonly performed in patients after OHCA, its diagnostic utility remains poorly characterized. Prospective studies are needed for appropriate imaging selection and their potential impact on treatment and outcome.

Use of Emergency Medical Services by Police.

OBJECTIVES: Many police officers receive medical training for limited assessments and interventions. In most situations where medical issues arise, however, emergency medical services (EMS) are called for evaluation, treatment, and transport. Given the limited amount of information about such encounters we examined officer calls for EMS help in a single system to better describe these encounters. METHODS: Requests for medical help from a fire-based EMS system by police in a moderate-sized city in 2014 and 2015 were identified. In this system, fire department resources are requested for initial evaluations of any medical complaint. Data were extracted from fire records including disposition, transportation from scene, type of injury or illness, and vital signs. Data analysis used descriptive statistics. RESULTS: 4,792 calls were made, representing 2.2% of all police-citizen interactions and 4.2% of all EMS calls. A total of 61.2% of calls resulted in transport to hospital. Of those, 5.6% required fire-based advanced life support; the remainder were transported by private basic life support ambulance or non-medical means. Most requests were for trauma (51.4%), followed by medical (24.7%), drug/alcohol use (17.1%), and psychiatric (6.7%). Vital signs tended to be within normal limits including 72.7% of pulses, 65.1% of systolic blood pressures, and 90.5% of respiratory rates. CONCLUSION: Requests for EMS assistance from police were common. Most calls involved patients with normal vital signs who did not require advanced life support transport. Further research is needed to identify situations where increased officer training and change in protocols could potentially change EMS response models and improve efficiency of the system.

Emergency department utilization by a jail population.

BACKGROUND: Incarcerated individuals represent a significant proportion of the US population and face unique healthcare challenges. Scarce articles have been published about emergency department (ED) care of these patients. We studied the ED visits from one urban jail to better describe this population. METHODS: A cohort study design was used, identifying patients who were sent to the ED from a city jail in 2015. Demographics, triage information, length of stay, number of studies, billing codes, diagnoses, and disposition data were collected. These were compared to the overall ED patient population in the same year. RESULTS: 868 ED visits by jail patients occurred, representing 1.3% of the ED census. Compared to the general population, incarcerated patients were younger (32.1 years vs. 44.0 years, p < .01), healthier based on Elixhauser comorbidity scores (0.71 vs. 0.98, p < .01), and had lower admission rates (11.29% vs. 21.54%, p < .01). An abnormal vital sign was noted in 25% of incarcerated patients. Laboratory (61% vs. 57%, p < .02) and radiologic (63% vs 45%, p < .001) testing was more frequent for inmates and length of stay was longer (271 vs. 225 min, p < .01). CONCLUSION: ED visits from jail were common, involving a relatively young and healthy population with a low incidence of abnormal vital signs and admission. Given the high costs associated with ED care and the medical resources available at some jails, further study should evaluate if increased jail medical capabilities could improve care and decrease costs by decreasing ED visits.

Emergency Department Documentation of Alleged Police Use of Excessive Force in Cases Where Formal Complaints Are Ultimately Filed.

BACKGROUND: Emergency physicians encounter patient concerns of police use of excessive force (UOEF). However, unlike other forms of potential assault, there are no guidelines for documentation of these encounters. Our objective was to examine the adequacy of emergency department documentation of injuries from police encounters where formal complaints of UOEF were later filed with the law enforcement agency. METHODS: A retrospective cohort design was used, identifying all citizen complaints of UOEF to a single police department in a 3-year period. Emergency department records associated with these encounters were then accessed and evaluated using standards for other forms of abuse and assault. RESULTS: Of 235 complaints, 33 (14.0%) presented to the emergency department within 7 days of the incident and were able to provide a history. For these subjects, 13 charts (39.4%) contained 3 or more of the 4 components thought to be necessary in cases of potential assault, and 11 (33.3%) contained documentation that should not be present: the guilt of the patient, subjective terminology by the provider, and/or documentation of law enforcement's description of the events as the only factual history. Of the total, 14 charts (42.4%) documented the patient's concern for UOEF. CONCLUSIONS: In this limited study, documentation of encounters where patients later filed a formal complaint of UOEF by law enforcement did not meet the standards for other forms of assault and abuse, having the potential to impact both the citizens and officers involved. Further study is necessary to identify the best practice guidelines for emergency physicians when they encounter patients injured in police encounters.

Polytrauma from Unintentional Pressure Cooker Explosion: A Case Report.

BACKGROUND: Pressure cookers are common kitchen appliances with a good safety record and only rare associated explosions. CASE REPORT: Here we present a case of unintentional pressure cooker explosion leading to polytrauma with injuries including pneumothorax, intracranial hemorrhage, open skull fracture, and multiple facial fractures. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Extreme forces and temperatures are involved in pressure cooking. Given the infrequent but real risk of mechanical failure and the increasing use of such devices to create intentional explosions, emergency physicians should be aware of the potentially significant blast injuries that can be associated with them.

A Novel Approach to Medical Student Peer-assisted Learning Through Case-based Simulations.

INTRODUCTION: Peer-assisted learning (PAL) is the development of new knowledge and skills through active learning support from peers. Benefits of PAL include introduction of teaching skills for students, creation of a safe learning environment, and efficient use of faculty time. We present a novel approach to PAL in an emergency medicine (EM) clerkship curriculum using an inexpensive, tablet-based app for students to cooperatively present and perform low-fidelity, case-based simulations that promotes accountability for student learning, fosters teaching skills, and economizes faculty presence. METHODS: We developed five clinical cases in the style of EM oral boards. Fourth-year medical students were each assigned a unique case one week in advance. Students also received an instructional document and a video example detailing how to lead a case. During the 90-minute session, students were placed in small groups of 3-5 students and rotated between facilitating their assigned cases and participating as a team for the cases presented by their fellow students. Cases were supplemented with a half-mannequin that can be intubated, airway supplies, and a tablet-based app (SimMon, $22.99) to remotely display and update vital signs. One faculty member rotated among groups to provide additional assistance and clarification. Three EM faculty members iteratively developed a survey, based on the literature and pilot tested it with fourth-year medical students, to evaluate the course. RESULTS: 135 medical students completed the course and course evaluation survey. Learner satisfaction was high with an overall score of 4.6 on a 5-point Likert scale. In written comments, students reported that small groups with minimal faculty involvement provided a safe learning environment and a unique opportunity to lead a group of peers. They felt that PAL was more effective than traditional simulations for learning. Faculty reported that students remained engaged and required minimal oversight. CONCLUSION: Unlike other simulations, our combination of brief, student-assisted cases using low-fidelity simulation provides a cost-, resource- and time-effective way to implement a medical student clerkship educational experience.

Missed appendicitis: did unexpected intraluminal densities play a role?

A healthy 19-year-old boy presented to our emergency department with abdominal pain. His history, examination and laboratory evaluation raised concern for appendicitis. A CT study of the abdomen and pelvis was carried out by the radiologist and emergency physician and was notable only for a large amount of unexpected high-attenuation intraluminal material. With further history, this was thought to be most likely retained bismuth from over-the-counter medicine ingestion. The patient was discharged home without a diagnosis. Further review of the CT scan by a second radiologist revealed a concern for appendiceal enlargement and associated free fluid. The patient was called back for further evaluation and treatment and ultimately an appendectomy was performed. Physicians should be aware of the causes and impact of unexpected radiopaque intraluminal contents on radiological studies. Most commonly from ingested medicine, such findings can obscure mucosal details, mimic active bleeding or create a distraction from other abnormalities.

Emergency Medicine Resident Perceptions of Medical Professionalism.

INTRODUCTION: Medical professionalism is a core competency for emergency medicine (EM) trainees; but defining professionalism remains challenging, leading to difficulties creating objectives and performing assessment. Because professionalism is dynamic, culture-specific, and often taught by modeling, an exploration of trainees' perceptions can highlight their educational baseline and elucidate the importance they place on general conventional professionalism domains. To this end, our objective was to assess the relative value EM residents place on traditional components of professionalism. METHODS: We performed a cross-sectional, multi-institutional survey of incoming and graduating EM residents at four programs. The survey was developed using the American Board of Internal Medicine's "Project Professionalism" and the Accreditation Council of Graduate Medical Education definition of professionalism competency. We identified 27 attributes within seven domains: clinical excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect for others. Residents were asked to rate each attribute on a 10-point scale. We analyzed data to assess variance across attributes as well as differences between residents at different training levels or different institutions. RESULTS: Of the 114 residents eligible, 100 (88%) completed the survey. The relative value assigned to different professional attributes varied considerably, with those in the altruism domain valued significantly lower and those in the "respect for others" and "honor and integrity" valued significantly higher (p<0.001). Significant differences were found between interns and seniors for five attributes primarily in the "duty and service" domain (p<0.05). Among different residencies, significant differences were found with attributes within the "altruism" and "duty and service" domains (p<0.05). CONCLUSION: Residents perceive differences in the relative importance of traditionally defined professional attributes and this may be useful to educators. Explanations for these differences are hypothesized, as are the potential implications for professionalism education. Because teaching professional behavior is taught most effectively via behavior modeling, faculty awareness of resident values and faculty development to address potential gaps may improve professionalism education.