Bottle it up: Prehospital management of an AV fistula bleed using a bottle cap.

Hemorrhage from arteriovenous fistula sites is a known complication with potentially fatal consequences. The management of AV fistula hemorrhage has historically included direct pressure, tourniquet use, and/or surgical management. We describe a case of a 71-year-old female with hemorrhage from an AV fistula site that was successfully managed in the prehospital setting using a simple bottle cap.

Air Medical Transportation of Injured Operational Canines.

Operational canines (OpK9s) are frequently injured in the line of duty and may benefit from specialized medical transport, including air medical transport. Reports of such transports can be found in the popular press, but there is a lack of research aimed at quantifying and examining these transports. We sent a survey to 295 programs in the United States identified through the Atlas and Database of Air Medical Services database to inquire about OpK9 transports and program policies and procedures for these transports. Of those 295 programs, we received 147 responses with 15 programs reporting that they have transported at least 1 OpK9. Programs also provided insight into policies and procedures that they have established for these types of transports. Although not all air medical programs will choose to complete this type of transport, we recommend that those that do establish policies and procedures to prepare for successful transports.

Acute Dystonia Versus Neuroleptic Malignant Syndrome Without Fever in an Eight-Year-Old Child.

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication of the use of certain medications. It is being seen more often in the pediatric population because of the increasing use of both typical and atypical antipsychotics in children. Rapid recognition of NMS is important to emergency physicians because timely treatment can be life saving. Acute dystonia is also a well-known and more common adverse effect of certain types of antipsychotics, more commonly seen with the typical antipsychotics versus the atypical antipsychotics. We describe a case of a pediatric patient who developed an acute dystonic reaction versus NMS soon after starting aripiprazole. We compare this case with the other documented cases of acute dystonia and NMS after initiating aripiprazole in the pediatric population.

Emergency medical services Milestones 2.0: What has changed?

Background: Since 2015, development of competencies by emergency medical services (EMS) fellows have been evaluated using the EMS Milestones 1.0 developed by a working group consisting of relevant stakeholders convened by the Accreditation Council for Graduate Medical Education (ACGME). Feedback from users and data collected from the milestones assessments in the interim indicated a need for revision of the original milestones. In May 2021, the Milestones 2.0 working group was convened for the purpose of revising this specialty-specific assessment tool. Methods: A working group consisting of representatives from American Board of Emergency Medicine, the Review Committee for Emergency Medicine, and volunteers selected by the ACGME Milestones Committee, chaired by the ACGME vice president for milestones development, was convened using a virtual platform to revise the milestones and develop a supplemental guide for use along with the Milestones 2.0. There were no in-person meetings of this working group due to the COVID-19 pandemic. Results: Data from milestones reporting, discussion within the working group, stakeholder input, and public commentary were used to revise the original milestones. A new supplemental guide to enhance milestone usability and provide recommended resource materials was also developed for use alongside the milestones. Discussion: The EMS Milestones 2.0 and accompanying supplemental guide provide an updated framework for fellowship programs to use as a guide for developing the competencies necessary for independent practice as EMS physicians and in the formal, competency-based evaluation of trainees as required by the ACGME.

Preliminary reports in the emergency department: is a subspecialist radiologist more accurate than a radiology resident?

RATIONALE AND OBJECTIVES: To determine whether emergency department (ED) preliminary reports rendered by subspecialist attending radiologists who are reading outside their field of expertise are more accurate than reports rendered by radiology residents, and to compare error rates between radiologists and nonradiologists in the ED setting. MATERIALS AND METHODS: The study was performed at a large academic medical center with a busy ED. An electronic preliminary report generator was used in the ED to capture preliminary interpretations rendered in a clinical setting by radiology residents, junior attendings (within 2 years of taking their oral boards), senior attendings, and ED clinicians between August 1999 and November 2004. Each preliminary report was later reviewed by a final interpreting radiologist, and the preliminary interpretation was adjudicated for the presence of substantial discordances, defined as a difference in interpretation that might immediately impact the care of the patient. Of the 612,890 preliminary reports in the database, 65,780 (11%) met inclusion criteria for this study. A log-linear analysis was used to assess the effects of modality and type of author on preliminary report error rates. RESULTS: ED clinicians had significantly higher error rates when compared with any type of radiologist, regardless of modality. Within the radiologists, residents and junior attendings had lower error rates than did senior attendings, but the differences were not statistically significant. CONCLUSION: Subspecialized attending radiologists who interpret ED examinations outside their area of expertise have error rates similar to those of radiology residents. Nonradiologists have significantly higher error rates than radiologists and radiology residents when interpreting examinations in the ED.

An evidence-based approach to managing acute otitis media.

Acute otitis media is one of the most common pediatric illnesses; however, there is considerable controversy in its management. While most cases are treated with antibiotics, there is a growing concern regarding antibiotic overuse and subsequent drug resistance. Researchers in the Netherlands have developed a "watchful waiting" (ie, an observation approach) that has been successful in treating acute otitis media, although it has not gained widespread popularity in the United States. This review will summarize the latest research on diagnosing acute otitis media as well as different treatment regimens, including the efficacy of the watchful-waiting approach.

Emergency department utilization by HIV-positive adults in the HAART era.

BACKGROUND: No published study has analyzed emergency department (ED) utilization by human immunodeficiency virus (HIV)-positive adults in the highly active antiretroviral therapy (HAART) era. AIMS: The purpose of this study is to describe the demographic and HIV-specific variables associated with ED utilization by HIV-positive adults and their diagnoses when discharged from the ED or subsequently from the hospital. METHODS: We conducted a retrospective cohort study of all HIV-positive adults cared for at a tertiary center HIV clinic and ED (1 January-31 December 2006). Demographic, HIV clinical, and HIV lab variables were abstracted from the clinic database. ED/hospital diagnoses coded by the ICD-9 Diseases/Injuries Tabular Index were abstracted from identified discharge records. We used multivariate logistic regression to compute odds ratios (OR) of ED utilization based on the abstracted variables. We described the cohort and diagnoses using descriptive statistics. RESULTS: A total of 356 patients met inclusion criteria. Their mean age was 42.7 years, and 77.2% of included patients were male; 52.5% were Caucasian and 47.5% non-Caucasian; 72 patients (20.2%) presented to the ED during the study period [153 visits; 37 (10.4%) required hospitalization (61/153 visits)]. Income level and mean 2006 viral load had a significant association (p < 0.05) with ED utilization. Of 155 ICD-9 ED discharge diagnoses, ill-defined symptoms/signs (25.2%), injury (18.7%), and musculoskeletal disorders (11.6%) were most prevalent. Of 450 ICD-9 hospital discharge diagnoses, endocrine/metabolic (13.3%), psychiatric (12.2%), infectious/parasitic (12%), and circulatory disorders (11.8%) were most prevalent. CONCLUSION: In this study of HIV-positive adults, income level and mean 2006 viral load had a significant association with ED utilization. Noninfectious diagnoses were alone most prevalent in ED discharged, but not hospitalized, patients.