Evaluation and management of urethral foreign bodies and description of a novel ultrasound-guided catheter-based extraction technique.

There are numerous reports in the medical literature documenting urethral foreign bodies with nearly all cases found in men and often associated with underlying psychiatric disorders, autoerotic stimulation, and/or intoxication. Patients most commonly presented with localized penile pain, hematuria, dysuria, and occasionally obstruction. Although endoscopic removal by a urologist is often the first-line treatment, this report describes evaluation and management considerations and presents a novel extraction technique that may allow emergency physicians in consultation with urology to perform removal of some unusual urethral foreign bodies in the emergency department. We report a novel extraction technique using a pediatric foley catheter under ultrasound guidance that has been applied during multiple encounters with 2 individuals who have each presented multiple times at a single emergency department (ED) for evaluation because of urethral foreign body insertion. The foreign body materials have ranged from small pieces of rubber to cellophane to styrofoam and most commonly plastic utensils. Urologic extraction may be required in some cases, but ED removal can be considered. A final discussion of the creation of a multidisciplinary care plan to address resource use concerns also is described.

Energy drink exposures reported to Texas poison centers: Analysis of adverse incidents in relation to total sales, 2010-2014.

The ill-defined term "energy drink" includes a disparate group of products (beverages, shots, concentrates, and workout powders) having large differences in caffeine content and concentration and intended use. Hence, inaccurate conclusions may be drawn when describing adverse events associated with "energy drinks". The FDA is considering new regulation of these products but product specificity is needed to evaluate safety. To help address this, we queried Texas Poison Center Network data for single substance exposures to "energy drinks" from 2010 to 2014, then analyzed adverse events by product type. We specifically compared energy beverage exposures with sales data for the same time period to evaluate the safety profile of this category of energy drinks. Among 855 documented "energy drink" exposures, poison center-determined outcome severity revealed 291 with no/minimal effects, 417 judged nontoxic or minor/not followed, 64 moderate and 4 major effects, and no deaths. Serious complications included 2 seizures and 1 episode of ventricular tachycardia. Outcome severity by category for beverages: 11 moderate/1 major effects (none in children <17 years); shots: 19 moderate/2 major; non-liquids: 16 moderate/1 major; concentrates: 7 moderate; unknown: 10 moderate. Call incidence to poison centers for beverage type exposures was 0.58 (for moderate effects) and 0.053 (for major) per hundred million units sold. Small volume and concentrated products were associated with a greater number of adverse effects than beverage versions of "energy drinks".

Intentional Misuse and Abuse of Loperamide: A New Look at a Drug with "Low Abuse Potential".

BACKGROUND: Despite its opioid properties, loperamide has long been thought to have low abuse potential due to its poor absorption from the gastrointestinal tract and limited potential to cross the blood-brain barrier. A recent patient reportedly taking loperamide to avoid heroin withdrawal symptoms, at doses approximately 100 times those recommended, directed our attention to this issue. OBJECTIVES: 1) Investigate number of cases of intentional loperamide abuse and misuse reported to poison centers between 2009 and 2015; 2) Compile reports of clinical effects of loperamide abuse; and 3) Search for evidence of increasing Internet interest in the central opioid effects of loperamide. METHODS: For the years 2009 thru 2015, we reviewed exposure calls related to misuse/abuse of loperamide in the Texas Poison Center Network's database and the National Poison Data System. We used Google trend analysis to detect evidence of increased Internet interest in the illicit use of loperamide. RESULTS: Between 2009 and 2015, the number of misuse/abuse calls related to loperamide alone nearly doubled, with about one-third of cases occurring in teens and young adults in their 20s. Of particular concern are reports of significant cardiotoxic effects (∼18% of cases), including conduction defects and various dysrhythmias, sometimes leading to death. Google Trends analysis demonstrates an increasing number of searches for "loperamide high" and "loperamide withdrawal" beginning in 2011. CONCLUSIONS: Loperamide misuse/abuse seems to be on the rise. Given its propensity to induce conduction disturbances and dysrhythmias at very high doses, emergency physicians should be vigilant for this form of drug abuse.

The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine.

BACKGROUND: Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support women's professional development in both community and academic EM settings. METHODS: We formed a working group from the leadership of two EM women's organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. RESULTS: An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. CONCLUSIONS: Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

STEMI Associated with Overuse of Energy Drinks.

Coronary artery disease (CAD) and ST-elevation myocardial infarction (STEMI) are predominantly diseases of middle-aged and older adults and when found in younger adults are usually associated with a strong family history. However, this report details the case of a nonobese 26-year-old Hispanic male who presented with an acute STEMI despite having no family history or other apparent risk factors for CAD or STEMI beyond a two pack-year smoking history and excessive energy drink consumption. The patient reported consuming between eight and ten 473 mL cans per day. Cardiac catheterization subsequently confirmed total occlusion of his left circumflex coronary artery.

Changes in insurance status and emergency department visits after the 2008 economic downturn.

OBJECTIVES: As the U.S. economy began its downward trend in 2008, many citizens lost their jobs and, ultimately, their employer-sponsored health care insurance. The expectation was that many of the newly uninsured would turn to emergency departments (EDs) for their health care. This study was undertaken to determine, first, if changes in the insurance status of the general population were reflected in the ED insurance payer mix and, second, whether there was evidence of an increased reliance on the ED as a continuing source of health care for any payer group(s). METHODS: This was a retrospective observational study using public data files from the National Hospital Ambulatory Medical Care Survey for Emergency Departments for years 2006 through 2010 (2008 ± 2 years). Changes in the relative proportions of ED visits funded annually by private insurance, Medicaid, Medicare, and self-pay (uninsured) were analyzed using a logistic model. Poisson regression was used to compare trends in the rates of ED visits for each payer type (i.e., number of ED visits per 100 persons with each insurance type). A linear spline term was used to determine if there was a change in each risk estimate after 2008 compared to the risk estimate before 2008. RESULTS: Before 2008, the odds of an ED visit being funded by private insurance increased by 4% per year (odds ratio [OR] = 1.04, 95% confidence interval [CI] = 0.98 to 1.10; p = 0.15), but after 2008 the odds reversed, decreasing by nearly 10% per year (OR = 0.91, 95% CI = 0.85 to 0.97; p = 0.02). Medicaid-funded visits demonstrated opposite trends with a small decreasing trend of 2% per year before 2008 (OR = 0.98, 95% CI = 0.92 to 1.04; p = 0.52), followed by a significantly increasing trend of 20% per year after 2008 (OR = 1.20, 95% CI = 1.12 to 1.27; p = 0.001). The growth in Medicaid-funded ED visits was attributable to increased numbers of visits by both pediatric (<18 years old) and non-elderly adult (19 to 64 years old) patients. For both Medicaid and private insurance visits, the change in trend in 2008 was statistically significant (p < 0.001 and p = 0.004, respectively). Self-pay visits were fairly steady before 2008 and then increased by about 5% per year after 2008, but this was not statistically significant (OR = 1.05, 95% CI = 0.96 to 1.14; p = 0.46), nor was the change in trend (p = 0.29). The results for Medicare-funded visits were also small and not statistically significant. There was also evidence of increased reliance on the ED by Medicaid-funded patients based on the comparison of ED visit rates. After 2008, the incidence rate ratio (IRR) for Medicaid-funded visits increased by 10% per year (IRR = 1.10, 95% CI = 1.10 to 1.10; p < 0.001) while the IRR for the other three payer groups changed about 1% per year (IRR = 0.99, 95% CI = 0.99 to 0.099; p < 0.001), indicating an increasing utilization of the ED by patients with Medicaid-funded care. CONCLUSIONS: After 2008, Medicaid patients were more dependent on ED services than uninsured, Medicare, or privately insured patients. Medicaid patients made up an increasing proportion of ED patients, and the rate of usage of ED services by all ages of Medicaid patients was significantly greater than that of the other three payer groups.

A research agenda for gender and substance use disorders in the emergency department.

For many years, gender differences have been recognized as important factors in the etiology, pathophysiology, comorbidities, and treatment needs and outcomes associated with the use of alcohol, drugs, and tobacco. However, little is known about how these gender-specific differences affect ED utilization; responses to ED-based interventions; needs for substance use treatment and barriers to accessing care among patients in the ED; or outcomes after an alcohol-, drug-, or tobacco-related visit. As part of the 2014 Academic Emergency Medicine consensus conference on "Gender-Specific Research in Emergency Care: Investigate, Understand and Translate How Gender Affects Patient Outcomes," a breakout group convened to generate a research agenda on priority questions related to substance use disorders.

Emergency Department Pneumonia Patients Who do not Meet the Six-Hour Criteria for Antibiotic Administration: Do They Have a Different Clinical Presentation?

BACKGROUND: The Joint Commission (JC) has set a quality of care standard for emergency department (ED) patients diagnosed with community acquired pneumonia (CAP) that states that they are to receive antibiotics within six hours of presentation to the ED. Hospitals have been able to demonstrate that the majority of patients meet these criteria, yet there are still many who do not. Previously published studies have reported that there are several issues that contribute to prolonged times to antibiotic administration including ED crowding and atypical clinical presentations. This study was undertaken to identify factors existing early in the patient encounter that may be associated with failure to meet the Joint Commission's six-hour standard for antibiotic administration. METHODS: This was an IRB-approved, retrospective observational study covering 36 months in an academic emergency department. All adults with an admission diagnosis of CAP were eligible but were excluded if their discharge diagnosis was not CAP, if hospitalized within the previous 14 days, or if HIV positive. Univariate analysis and multiple logistic regression with stepwise variable selection were performed comparing patients who met and did not meet JC standards. The analysis included demographics (age, sex), chief complaint at triage and to doctor (fever, dyspnea, cough, chest pain, weakness/fatigue, abdominal pain), presence of altered mental status, triage vital signs, co-morbidities, day of week and time of day of presentation. RESULTS: A total of 736 cases were eligible; 199 cases met exclusion criteria; 43 charts were unavailable; 494 were included in the study group (363 with complete antibiotic time records; 131 were incomplete). From the univariate analysis, respiratory rate (RR) and oxygen saturation were the only factors that met Bonferroni criteria for statistical significance when comparing those who met and did not meet the JC six-hour criteria (RR 25 ± 9 vs 22 ± 6 breaths/minute, respectively, P = 0.002; oxygen saturation 87 ± 10% vs 92 ± 5%, respectively, P < 0.001). Multiple logistic regression identified triage pulse rate, oxygen saturation, presence of altered mental status, hour of day, and day of week as variables associated with time to antibiotic administration. Chances for meeting the standard were increased by 10% for each 5-beat increase in pulse rate or 1% decrease in oxygen saturation. If the person exhibited altered mental status, they were > 3.5 times more likely to meet the 6-hour criteria. If they presented to ED between 3 PM and 10 PM chances of meeting criteria were reduced by about 65%. If they presented on a Thursday, chances improved 2.8 times. CONCLUSIONS: Compared to patients who did meet Joint Commission criteria, those who did not receive antibiotics within 6 hours were likely to have triage pulse rates and O(2) saturation levels closer to normal, thus contributing to diagnostic uncertainty. They were also likely to present to the ED at the most crowded time of day. Likelihood to meet JC criteria was improved if O(2) saturation was below normal, pulse rate was elevated, if they exhibited mental confusion, or if they presented to the ED very early or very late in the day, or on a lower census day.

The Society for Academic Emergency Medicine and Association of Academic Chairs in Emergency Medicine 2009-2010 emergency medicine faculty salary and benefits survey.

OBJECTIVES: he objective was to report the results of a survey conducted jointly by the Society for Academic Emergency Medicine (SAEM) and the Association of Academic Chairs in Emergency Medicine (AACEM) of faculty salaries, benefits, work hours, and department demographics for institutions sponsoring residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Emergency Medicine (RRC-EM). METHODS: Data represent information collected for the 2009-2010 academic year through an electronic survey developed by SAEM and AACEM and distributed by the Office for Survey Research at the University of Michigan to all emergency department (ED) chairs and chiefs at institutions sponsoring accredited residency programs. Information was collected regarding faculty salaries and benefits; clinical and nonclinical work hours; sources of department income and department expenses; and selected demographic information regarding faculty, EDs, and hospitals. Salary data were sorted by program geographic region and faculty characteristics such as training and board certification, academic rank, department title, and sex. Demographic data were analyzed with regard to numerous criteria, including ED staffing levels, patient volumes and length of stay, income sources, salary incentive components, research funding, and specific type and value of fringe benefits offered. Data were compared with previous SAEM studies and the most recent faculty salary survey conducted by the Association of American Medical Colleges (AAMC). RESULTS: Ninety-four of 155 programs (61%) responded, yielding salary data on 1,644 faculty, of whom 1,515 (92%) worked full-time. The mean salary for all faculty nationwide was $237,884, with the mean ranging from $232,819 to $246,853 depending on geographic region. The mean salary for first-year faculty nationwide was $204,833. Benefits had an estimated mean value of $48,915 for all faculty, with the mean ranging from $37,813 to $55,346 depending on geographic region. The following factors are associated with higher salaries: emergency medicine (EM) residency training and board certification, fellowship training in toxicology and hyperbaric medicine, higher academic rank, male sex, and living in the western and southern regions. Full-time EM faculty work an average of 20 to 23 clinical hours and 16 to 19 nonclinical hours per week. CONCLUSIONS: The salaries for full-time EM faculty reported in this survey were higher than those found in the AAMC survey for the same time period in the majority of categories for both academic rank and geographic region. On average, female faculty are paid 10% to 13% less than their male counterparts. Full-time EM faculty work an average of 20 to 23 clinical hours and 16 to 19 nonclinical hours per week, which is similar to the work hours reported in previous SAEM surveys.