Burnout in Military Emergency Medicine Resident Physicians: A Cross-Sectional Study With Comparisons to Other Physician Groups.

INTRODUCTION: Physician burnout is of growing concern in the medical community and in emergency medicine (EM) in particular. It is unclear whether higher levels of burnout are associated with poorer academic or clinical performance. EM residency in military environments compared to civilian residencies has unique considerations related to additional military-specific training and operational requirements, which may contribute to burnout. The prevalence and effects of burnout on military EM resident physicians have not been investigated. METHODS: In this institutional review board-approved cross-sectional study, the prevalence of burnout and its effect on academic performance of 30 EM residents in a single 4-year military EM training program was examined. The primary instrument utilized to assess for burnout was the Maslach Burnout Inventory Health Services Survey (MBI-HSS). The primary definition of burnout utilized was a high score in both emotional exhaustion (EE) and depersonalization (DP), and a low score in personal achievement (PA). Additionally, at risk for burnout was defined as moderate or high scores in both EE and DP and low scores in PA. A secondary definition of burnout utilized was any high score in EE or DP, or a low score in PA. The findings in this cohort were compared with published reports of burnout in civilian EM resident and attending physicians as well as military orthopedic physicians. The annual American Board of Emergency Medicine In-Training Exam (ABEM-ITE) percentile ranks for each volunteer in that same academic year were collected as a measure of academic achievement. RESULTS: Thirty of the 40 eligible resident physicians consented to participate in this research project (75%). All 30 completed the MBI-HSS and ABEM-ITE. Burnout, using the primary definition, was found in 10% of residents with an additional 13% at risk for burnout. Using the secondary definition of burnout, 73% of residents demonstrated burnout. The prevalence of burnout as measured by the MBI-HSS was similar to that reported in civilian EM resident and practicing physician groups but 2.7 times the burnout rates found in a military orthopedic resident group. We found no relationship between any individual burnout measure in the MBI-HSS and the annual ABEM-ITE percentile scores. CONCLUSION: In a small study of military EM resident physicians, level of burnout as measured by the MBI-HSS is similar to other EM populations including civilian residents and practicing physicians, though it was much higher than that of military orthopedic residents. No relationship between presence or absence of burnout and academic performance as measured by the ABEM-ITE was found.

Respiratory Failure in a Child Due to Type 2 Postobstructive Pulmonary Edema.

BACKGROUND: Postobstructive pulmonary edema (POPE), sudden pulmonary edema after upper airway obstruction, is an important disease entity for pediatric emergency physicians to recognize and initiate prompt treatment. Type 1 POPE occurs after a sudden, severe upper airway obstruction, whereas type 2 POPE develops after acute relief of chronic airway obstructive. CASE: A 12-year-old boy, with a history of untreated sleep apnea, on postoperative day 2 from appendectomy, was brought to the emergency department in respiratory distress. The patient required urgent intubation, and copious pink frothy fluid was suctioned from the endotracheal tube. He was initially difficult to oxygenate, but with ventilator setting changes including a high positive end-expiratory pressure, the patient improved. He was discharged on hospital day 3 with nighttime BiPAP for home use. CONCLUSIONS: Type 2 POPE should be considered in a patient presenting with respiratory distress and a history of sleep apnea. Optimal ventilator management includes use of PEEP in the 10 to 15 cm H2O range. The roles of diuretics and steroids are controversial. Most patients will do well after a brief period of ventilatory support (24-48 hours). With the rise of ambulatory surgery, pediatric emergency physicians must be attuned to both the surgical and anesthetic complications that occur in the early postoperative period.

Agreement between resident and faculty emergency physicians in the application of NEXUS criteria for suspected cervical spine injuries.

BACKGROUND: The National Emergency X-Radiography Utilization Study (NEXUS) developed a decision rule for when cervical spine radiographs are required in the setting of trauma. To our knowledge, inter-rater reliability between resident and faculty emergency physicians has not been studied. OBJECTIVE: This study seeks to compare the inter-rater agreement of postgraduate year (PGY) 2-4 emergency medicine (EM) residents vs. EM faculty physicians. METHODS: A convenience sample of patients presenting to an urban, academic, Level II emergency department (ED) with complaints of cervical spine pain after trauma were enrolled. All subjects received separate examinations by an EM faculty physician and by a PGY 2-4 EM resident in a blinded fashion. Eighty subjects were enrolled in the study. RESULTS: Agreement for each of the NEXUS components were: posterior midline tenderness (PMT) 85.0% and κ = 0.70, intoxication (TOX) 95.0% and κ = 0.72, altered mental status (AMS) 87.5% and κ = 0.22, focal neurologic deficit (FND) 92.5% and κ = 0.21, and presence of a distracting injury (DIS) 88.8% and κ = 0.13. Overall agreement for need for radiographs was 77.5% and κ = 0.53. Sixty of the subjects received radiography (28 computed tomography, 40 plain films, 8 both). One fracture (C1 lamina) was detected in this dataset. Two of the five NEXUS criteria (PMT, TOX) demonstrated substantial agreement, two (AMS, FND) fair agreement, and one (DIS) slight agreement. CONCLUSIONS: Based on our findings, there was considerable difference in agreement between staff physicians and residents. This could be due to the level of experience of the provider or the subjectiveness of components the criteria.

Cardiac complications of adult methamphetamine exposures.

BACKGROUND: Methamphetamine use is an increasing problem in the United States. Despite the similarities to cocaine in clinical presentation, methamphetamine effects on the cardiovascular system are not as clearly understood. OBJECTIVES: The purpose of this retrospective review is to evaluate the cardiovascular outcomes of methamphetamine exposures reported to both the California Poison Control System (CPCS) and two Level 1 trauma centers. METHODS: CPCS records from 2000-2009, as well as inpatient and emergency department charts from two Level 1 trauma centers during the time frame of 2000-2004 were reviewed. Charts of adults with coded methamphetamine exposures were included. RESULTS: Records of 2356 adults with methamphetamine exposure were assigned levels of severity according to National Poison Data System Medical Outcomes Criteria. Out of the combined charts reviewed from the CPCS data and hospital registries, 584 cases were coded as minor effects, 450 as moderate effects, 208 as major effects, and 28 as deaths. Of the included 1270 cases, 627 electrocardiograms (ECGs) were analyzed. Together, troponins and ECGs showed evidence of myocardial ischemia in 82 total cases, which is 6.5% of the cases reviewed. Cocaine was a co-ingestant in 10 of the 82 cases. CONCLUSIONS: This study presents a large cohort of methamphetamine users. The study found that chest pain and myocardial ischemia were reported in a number of cases. Although no true incidence can be taken from this dataset, it provides a large-scale review of methamphetamine use and its possible association with acute coronary syndromes.

Measuring arterial oxygenation in a high altitude field environment: comparing portable pulse oximetry with blood gas analysis.

OBJECTIVE: High altitude environments present unique medical treatment challenges. Medical providers often use small portable pulse oximetry devices to help guide their clinical decision making. A significant body of high altitude research is based on the use of these devices to monitor hypoxia, yet there is a paucity of evidence that these devices are accurate in these environments. We studied whether these devices perform accurately and reliably under true mountain conditions. METHODS: Healthy unacclimatized active-duty military volunteers participating in mountain warfare training at 2100 m (6900 feet) above sea level were evaluated with several different pulse oximetry devices while in a cold weather, high altitude field environment and then had arterial blood gases (ABG) drawn using an i-STAT for comparison. The pulse oximeter readings were compared with the gold standard ABG readings. RESULTS: A total of 49 individuals completed the study. There was no statistically significant difference between any of the devices and the gold standard of ABG. The best performing device was the PalmSAT (PS) 8000SM finger probe with a mean difference of 2.17% and SD of 2.56 (95% CI, 1.42% to 2.92%). In decreasing order of performance were the PS 8000AA finger probe (mean ± SD, 2.54% ± 2.68%; 95% CI, 1.76% to 3.32%), the PS 8000Q ear probe (2.47% ± 4.36%; 95% CI, 1.21% to 3.75%), the Nonin Onyx 9500 (3.29% ± 3.12%; 95% CI, 2.39% to 4.20%), and finally the PS 8000R forehead reflectance sensor (5.15% ± 2.97%; 95% CI, 4.28% to 6.01%). CONCLUSIONS: Based on the results of this study, results of the newer portable pulse oximeters appear to be closely correlated to that of the ABG measurements when tested in true mountain conditions.

Psychiatric implications of adolescent methamphetamine exposures.

OBJECTIVES: Methamphetamine abuse has reached epidemic proportions during the last decade. Abuse among adolescents is linked to increased rates of depression and suicidal ideation. Sources suggest that there is an increase rate of suicide attempts in the methamphetamine-abusing adolescent patient population. Our study seeks to examine adolescent methamphetamine exposures reported to the California Poison Control System during the past decade of suicidal ideation and suicide attempts in comparison to rates reported by population-based surveys. METHODS: The records of the California Poison Control System were searched for methamphetamine exposures from 2000 to 2009. All charts of patients identified between the ages of 11 and 18 years were reviewed and abstracted. RESULTS: The records of 293 youth between the ages of 11 and 18 years were identified and assigned levels of severity according to parameters set by the National Poison Data System Medical Outcome Criteria of the American Association of Poison Control Centers. Charts were categorized as follows: 11 as major, 52 as moderate, and 75 as minor. The remainder of the charts were not evaluated because of no effect (n = 13) or unable to follow (n = 142). In this cohort, more females were reported than males (57%). The most common presenting symptom in this patient population was agitation (39%). The most common events were suicidal ideation (31%) and suicide attempts (21%). CONCLUSIONS: In this data set, adolescent methamphetamine exposures were associated with increased rates of suicidal ideation and suicide attempts that are disproportionate to population-based surveys during the same period.

Emergency department presentation of superior mesenteric artery syndrome: two cases in Marine Corps recruits.

BACKGROUND: Superior mesenteric artery (SMA) syndrome is a relatively rare etiology of proximal intestinal obstruction. Obstruction results from marked narrowing of the angle between the SMA and aorta, causing compression of the third portion of the duodenum, most commonly as a result of precipitous weight loss. Intermittent non-specific symptoms at presentation often result in a delayed diagnosis, thus the importance of being aware of this condition. OBJECTIVE: To familiarize emergency physicians with the presentation of SMA syndrome and discuss its diagnosis and management in the emergency department (ED). CASE REPORT: We present two cases of SMA syndrome identified in Marine Corps recruits presenting to our ED. CONCLUSION: Emergency physicians should include SMA syndrome in the differential diagnosis of abdominal pain and vomiting in individuals with predisposing factors.

Effect of deferasirox on iron absorption in a randomized, placebo-controlled, crossover study in a human model of acute supratherapeutic iron ingestion.

STUDY OBJECTIVE: In 2005, the Food and Drug Administration approved deferasirox as an oral iron chelating agent for chronic iron overload. To determine usefulness in management of acute iron ingestion, we study the effect of orally administered deferasirox in healthy human adults. METHODS: A double-blinded, placebo-controlled, randomized, crossover study of 8 healthy human volunteers was conducted. Subjects ingested 5 mg/kg of elemental iron in the form of ferrous sulfate. One hour after iron ingestion, subjects were randomized to receive 20 mg/kg of deferasirox or placebo. Serial iron levels were then obtained. A 2-week washout was used between study arms. The paired t test was used to compare area under time-concentration curves from baseline to both 12- and 24-hour iron levels between groups. RESULTS: Baseline serum iron levels were similar in the 2 groups. Deferasirox significantly reduced serum iron area under concentration-time curves compared with placebo during both 1 to 12 hours and 1 to 24 hours (12 hour=577 µmol-hour/L and 392 µmol-hour/L, 95% confidence interval for the difference 15.8 to 353.0 µmol-hour/L; 24 hour=808 µmol-hour/L and 598 µmol-hour/L, 95% confidence interval for difference 54.4 to 366.7 µmol-hour/L). CONCLUSION: Orally administered deferasirox significantly reduced serum iron levels when administered 1 hour after iron ingestion during the 12- and 24-hour periods after acute ingestion of 5 mg/kg of elemental iron in healthy human volunteers. Further study is required to determine optimal dosing, but deferasirox may be an important addition to current therapy for acute iron poisoning.

Acute multi-vessel coronary stent thrombosis.

BACKGROUND: Coronary artery stent thrombosis is a rare but often fatal complication associated with percutaneous coronary intervention (PCI) using both bare-metal stents and drug-eluting stents. Although strict adherence to dual anti-platelet therapy (aspirin plus clopidogrel) minimizes this risk, stent thrombosis will still occur in rare patients, leading to acute, subacute, or late life-threatening acute coronary syndromes. OBJECTIVES: To present a rare case of acute stent thrombosis involving multiple vessels to increase awareness of this life-threatening condition among emergency physicians, and to review the current guidelines for anti-platelet therapy in this patient population. CASE REPORT: A 52-year-old man who underwent PCI using drug-eluting stents in two separate coronary vessels presented to the Emergency Department within 2 h of discharge from the hospital with chest pain, dynamic electrocardiogram changes, and elevated cardiac markers. Despite compliance with the current recommendations for post-PCI anti-platelet therapy, urgent repeat catheterization revealed total thrombotic occlusion of both stents, requiring urgent repeat intervention. CONCLUSION: Despite patient compliance with the currently recommended anti-platelet regimen after stent therapy for coronary artery disease, acute stent thrombosis remains a rare but life-threatening risk in both the immediate and delayed post-intervention period. In addition, premature cessation of this anti-platelet therapy stands as the greatest risk factor for such thrombotic events. This case is presented to inform emergency physicians of the current post-PCI anticoagulation recommendations to help mitigate the risk of such complications.

The effect of bedside presentations in the emergency department on patient satisfaction.

BACKGROUND: Due to increasing time constraints, the use of bedside presentations in resident education has declined. We examined whether patient satisfaction in the emergency department is affected when first-year residents present at the bedside with attendings. METHODS: We performed an observational, prospective, nonblinded study in the emergency department of a military teaching hospital. We alternately assigned first-year residents to present a convenience sample of 248 patients to the attending physician at the patient's bedside or away from the patient. We measured patient satisfaction by using the Patient Satisfaction Questionaire-18 (PSQ-18), a validated survey instrument that utilizes a Likert scale, and additional nonvalidated survey questions involving Likert and visual analog scales. RESULTS: While the median PSQ-18 score of 74 (95% confidence interval [CI], 72-76) was higher for patient satisfaction when residents made bedside presentations than that for standard presentations, 72 (95% CI, 70-74), the difference did not reach statistical significance (P  =  .33). CONCLUSION: There was no significant difference in overall patient satisfaction between residents' bedside presentations and presentations to attendings away from the patient. Although not significant, the differences noted in PSQ-18 subscales of communication, general satisfaction, and interpersonal manner warrant further investigation. Patients did not appear to be uncomfortable with having their care discussed and with having subsequent resident education at the bedside. Future research on patient satisfaction after implementation of standardized bedside teaching techniques 5 help further elucidate this relationship.

Comparison of oral aspirin versus topical applied methyl salicylate for platelet inhibition.

BACKGROUND: Oral acetylsalicylic acid (aspirin) is the primary antiplatelet therapy in the treatment of acute myocardial infarction and acute coronary syndrome. Methyl salicylate (MS; oil of wintergreen) is compounded into many over-the-counter antiinflammatory muscle preparations and has been shown to inhibit platelet aggregation locally and to be absorbed systemically. OBJECTIVE: To assess the ability of topically applied MS to inhibit systemic platelet aggregation for patients who are unable to tolerate oral drug therapy. METHODS: A randomized, prospective, blinded, crossover study was conducted in 9 healthy men, aged 30-46 years. All subjects ingested 162 mg of aspirin or applied 5 g of 30% MS preparation to their anterior thighs. There was a minimum 2-week washout period between study arms. Blood and urine were collected at baseline and at 6 hours. An aggregometer measured platelet aggregation over time against 5 standard concentrations of epinephrine, and a mean area under the curve (AUC) was calculated. Urinary metabolites of thromboxane B(2) were measured by a standard enzyme immunoassay. Differences in and between groups at baseline and 6 hours were tested by the Wilcoxon signed-rank test. RESULTS: Baseline platelet aggregation did not differ significantly between the 2 arms of the study (median AUC [% aggregation(*)min]; binominal confidence intervals): aspirin 183; 139 to 292 versus MS 197; 118 to 445 (p = 0.51). Both aspirin and MS produced statistically significant platelet inhibition; aspirin decreased the AUC from 183; 139 to 292 to 85; 48 to 128 (p = 0.008) and MS decreased the AUC from 197; 118 to 445 to 112; 88 to 306 (p = 0.011). No significant difference was detected between baseline and 6-hour thromboxane levels for either aspirin (p = 0.779) or MS (p = 0.327). CONCLUSIONS: Topical MS and oral aspirin both significantly decrease platelet aggregation in healthy human volunteers.

Fever, sacral pain, and pregnancy: an incarcerated uterus.

UNLABELLED: Uterine incarceration is an uncommon but serious presentation in the emergency department that requires early recognition to improve maternal and fetal outcomes. CASE: A 29-year-old female, at 12 weeks gestation, presented to the emergency department (ED) with complaints of fever, sacral pain and urgency. Based on history and physical examination, she was found to have a retroverted, incarcerated uterus. After a failed attempt at reduction in the ED, her uterus was successfully reduced under general anesthesia. DISCUSSION: Pain and urinary difficulties, such as retention and hesitancy, are frequent in pregnancy, yet incarcerated uterus is an uncommon emergency department diagnosis that often presents with these symptoms. Clues to the diagnosis include a retroverted uterus, urinary retention, and pain in a patient presenting in the third to fourth months of gestation. Treatment is by manual reduction of the uterus. Complications range from spontaneous abortion to uterine rupture.

Pediatric sex group differences in location of snakebite injuries requiring antivenom therapy.

OBJECTIVE: The objective of this study is to examine the patterns of snakebite injury in pediatric patients that require antivenom therapy and to evaluate whether and when sex group differences exist. METHODS: We performed a nationwide, multicenter, retrospective evaluation of 24 regional poison centers from 2002 and through 2004 of data for antivenom therapy for Crotaline snakebites. Data points abstracted included the age of the victim, sex of the victim, and location of bite. We calculated contingency tables of the data with statistical significance by Fisher's exact test. RESULTS: We evaluated 204 records that involved pediatric patients; 3 of the patients had no recorded age. In 16 of the records, the bite location was not documented (2 children and 1 unknown age) or was listed as head/neck (1 child). These records were not included in the data analysis. There were bites in 136 males and 65 females. Males were more likely than females to suffer an injury to the upper extremity (56.6% vs. 26.2%; p<0.01). Males were more likely to suffer injuries to the upper extremity in all age groups (p <0.05) except for the group aged 10 through 12 years; in the group aged 10 through 12, we did not see significant differences between the sexes (p=0.729). Males are more likely to suffer an upper extremity bite with increasing age (p=0.029), while females showed no significant change in the location of bites (p=0.223). CONCLUSION: Male children were more likely than female children to suffer Crotaline snakebites that required antivenom therapy. In this population, significant differences between locations of snakebites were found. Males were more likely than females to be bitten in the upper extremities. This difference appears as early as 1 to 4 years of age.

Methamphetamine exposures in young children.

OBJECTIVES: Methamphetamine abuse is reaching epidemic proportions. As this occurs, the likelihood of accidental poisoning in children increases. We sought to evaluate the presentation, treatment, and outcome of pediatric methamphetamine exposures reported to the California Poison Control System. METHODS: This is a retrospective review of California Poison Control System records for methamphetamine exposure from 2000 through 2004. All charts of patients identified as younger than 6 years were reviewed and abstracted. RESULTS: The charts of 47 children younger than 6 years were identified and reviewed. Three were coded as minor effects, 3 as major effects, and 16 as moderate effects. The remainder of the charts were not evaluated because of no effect (n = 6), unrelated or confirmed nonexposure (n = 3), or unable to follow (n = 16). The most common presenting symptom was agitation (82%), whereas seizures were documented in only 2 cases (9%). Tachycardia was common (mean heart rate, 171 beats/min; confidence interval [CI], 154-187), whereas blood pressure (BP) (mean systolic BP, 120 mm Hg; CI, 104-136; and mean diastolic BP, 70 mm Hg; CI, 51-88) and rectal temperature (mean, 37.4 degrees C; CI, 36.9-37.9) were slightly elevated compared with normal values. Creatinine was documented in 6 cases and noted as normal in all (0.3IU/L; CI, 0.2-0.4), whereas creatine kinase was documented in 3 charts and elevated in all (mean 1984 IU/L; range, 212-4942 IU/L). Most cases (55%) received benzodiazepines as treatment, although only 2 received activated charcoal. Symptoms persisted for an average of 22 hours (CI, 16.3-27.2). No deaths were reported. CONCLUSIONS: In this series of children, methamphetamine exposure was strongly associated with agitation that was successfully treated with benzodiazepines. Tachycardia was common, although hypertension and hyperthermia were not. Laboratory studies were not routinely recorded. The clinical significance of elevated creatine kinase concentrations recorded in 3 children is unclear.

Antidote use in the critically ill poisoned patient.

The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit (N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient.

The Pittsburgh Decision Rule: triage nurse versus physician utilization in the emergency department.

The Pittsburgh Decision Rule (PDR) is a rule for ordering knee radiographs in patients with acute knee injuries. This study was designed to compare the utilization of the PDR between triage nurses and physicians. Consecutive patients presenting to the Emergency Department were enrolled. Nurses and physicians were blinded to each other's examinations. Of 182 subjects approached, 30 were excluded for incomplete data or refusal to obtain radiographs, leaving 152 subjects enrolled. Thirteen fractures (8.6%) were identified. Kappa scores were high for each component of the rule: mechanism of injury (fall or blunt trauma) kappa = 0.67, age (< 12 or > 50 years) kappa = 1, inability to ambulate kappa = 0.67 and overall kappa = 0.83. Four of 13 fractures (31%) would have been missed using the PDR, resulting in a sensitivity of 77% for both physicians and nurses, and a specificity of 57% for physicians and 58% for nurses. Triage nurses and physicians were able to apply the PDR to patients who presented with acute knee injuries with a high level of agreement. However, the PDR demonstrated poor sensitivity in this patient population.