The Kleinert modified dorsal finger splint for mallet finger fracture

Injuries to the hand and digits are commonly seen in the emergency department. Lacerations, contusions, puncture wounds, and fractures comprise the bulk of these injuries. A fracture to the dorsum of the distal phalanx can result in a mallet finger deformity. These fractures must be accurately diagnosed with the proper initial treatment begun. There is some disagreement over the best treatment approach and multiple different splints have been described in the literature. Conservative treatment with a finger splint is most commonly effective. We recommend a modified dorsal finger splint for these injuries. We describe a splint to properly treat the fracture, prevent complications, maximize patient comfort during rehabilitation, and prevent mallet finger deformity.

Evaluation of the Emergency Severity Index (version 3) triage algorithm in pediatric patients

OBJECTIVES

As demand for emergency services outpaces available allocated resources, emergency department (ED) triage systems face increasing scrutiny. Longer waits for care make the use of reliable, valid triage systems imperative to patient safety. Little is known about the reliability and validity of triage systems in children. The purpose of this study was to evaluate the reliability and validity of the Emergency Severity Index version 3 (ESIv.3) triage algorithm in a pediatric population.

METHODS

This two-phase investigation used both retrospective chart review and prospective, observational designs. Interrater reliability was evaluated using ED triage scenarios, a prospective cohort of ED patients presenting to triage, and retrospective triage assignments using the original triage note. ED triage nurses, nurse investigators, and physician investigators performed retrospective blinded triages using only the original triage note to assess reproducibility. In the second phase, validity was assessed using a retrospective analysis of observed resource use, ED length of stay, and hospitalization compared with resource utilization estimated at triage by the ESI.

RESULTS

In the reliability phase, weighted kappa for ED nurse triage of standard scenarios ranged from 0.84 to 1.00, representing excellent agreement. Twenty ED pediatric patients were triaged simultaneously by an ED triage nurse and the nurse investigator. Weighted kappa was 0.82 (95% confidence interval = 0.66 to 0.98), also representing strong agreement between raters. When used for retrospective chart review, the weighted kappa statistics ranged from 0.42 to 0.84, representing poor to good agreement among the different categories of reviewers. During the validity phase, 510 patients were included in the final data analysis. Hospitalization, ED length of stay, and resource utilization were strongly associated with ESIv.3 category.

CONCLUSIONS

The ESI triage algorithm demonstrated reliability and validity between triage assignment and resource use in this group of ED pediatric patients.

An electronic chart prompt to decrease proprietary antibiotic prescription to self-pay patients

OBJECTIVES

Emergency physicians unaware of patients' insurance status may prescribe expensive proprietary antibiotics for patients who cannot afford them. The objective of this study was to develop a clinical decision support system to display patient insurance status before prescription writing for outpatient conditions.

METHODS

This was a 26-week "before-and-after" trial at an urban emergency department (ED) with 78,000 visits/year treating a medically underserved population. Sixty-one prescribers, including attending physicians, residents, and physician assistants, participated. All patients older than 18 years of age discharged from the ED receiving antibiotic prescriptions were eligible. The electronic ED chart is linked to prescription-writing software, which includes a menu of 74 antibiotics. The system was programmed so that when an emergency physician accessed the prescription menu, a prompt appeared displaying insurance status. Prescribers also received educational interventions. The main outcome measure was the percentage of prescribers who reduced their prescription writing of proprietary antibiotics to self-pay patients. Data were analyzed with cluster techniques using SPSS 10.0 (SPSS Inc., Chicago, IL).

RESULTS

Of 594 prescriptions written for self-pay patients before prompt insertion, 158 (26.6%) were for proprietary antibiotics. After the intervention, self-pay patients received 564 antibiotic prescriptions, of which 117 (20.7%) were for proprietary drugs. Analyzed by prescriber, the reduction in the prescription rate for proprietary antibiotics was statistically significant (p = 0.03, chi(2) test). Patients with respiratory or urinary infections also had a statistically significant reduction in proprietary antibiotic prescription (p = 0.03).

CONCLUSIONS

A clinical decision support system, integrated into a prescription-writing program, can decrease the prescription of proprietary antibiotics for self-pay patients in the ED.

Emergency department digital radiology: moving from photos to pixels

Emergency department (ED) patient care relies heavily on radiologic imaging. As advances in technologic innovation continue to present opportunities to streamline and simplify the delivery of care, emergency medicine (EM) practitioners face the challenge of transitioning from a system of primarily film-based radiography to one that utilizes digitized images. The move to digital radiology can result in enhanced quality of patient care, reduction of errors, and increased ED efficiency; however, making this transition will necessarily involve changes in EM practice. As the technology evolves, digital radiology will gradually become ingrained into everyday practice because of these and other notable benefits; however, EM practitioners will need to overcome several challenges to make the transition smoothly and consider the potential impacts that this change will have on ED workflow. The authors discuss the benefits, challenges, and other operational considerations involved with the ED implementation of digital radiology and close by presenting guiding principles for current and future users. Despite the unresolved issues, digital radiology will mature as a technology and improve EM practice, making it one of the great information technology advances in EM.

Rapid Emergency Medicine Score can predict long-term mortality in nonsurgical emergency department patients

OBJECTIVES

To examine the Rapid Emergency Medicine Score (REMS) as a predictor of long-term (4.7 years) mortality in the nonsurgical emergency department (ED).

METHODS

This was a prospective cohort study. A total of 12,006 nonsurgical patients consecutively presenting to an adult ED at a 1,200-bed university hospital during a period of one year were enrolled. REMS (including blood pressure, respiratory rate, pulse rate, Glasgow Coma Scale score, peripheral oxygen saturation, and patient age) was calculated for all patients admitted to the ED. The statistical associations between REMS and long-term mortality were examined.

RESULTS

REMS could predict mortality over 4.7 years (hazard ratio, 1.26; p < 0.0001). Similar results were obtained in the major patient groups (chest pain, stroke, coma, dyspnea, and diabetes).

CONCLUSIONS

REMS was a powerful predictor of long-term mortality in patients attending the ED for a wide range of common nonsurgical disorders.

What's in the doctor's bag?

BACKGROUND

A doctor's bag is invaluable when you need to take part of the practice to the patient, or in the case of an emergency.

OBJECTIVE

This article aims to help new general practice registrars and experienced general practitioners consider what they may need in their doctor's bag.

DISCUSSION

The doctor's bag needs to be personalised to the requirements of each GP and their patient population. Decisions need to be made about the type of bag, stationery, equipment and medications carried. Some possible additions for a rural doctor's bag are included, as well as some general tips.

Difficult airway equipment in departments of emergency medicine in Ireland: results of a national survey

BACKGROUND AND OBJECTIVE

Adverse effects associated with difficult airway management can be catastrophic and include death, brain injury and myocardial injury. Closed-malpractice claims have shown prolonged and persistent attempts at endotracheal intubation to be the most common situation leading to disastrous respiratory events. To date, there has been no evaluation of the types of difficult airway equipment currently available in Irish departments of emergency medicine. The objective of this survey was to identify the difficult airway equipment available in Irish departments of emergency medicine.

METHODS

Departments of emergency medicine in the Republic of Ireland with at least one dedicated Emergency Medicine consultant were surveyed via telephone.

RESULTS

All of the departments contacted held at least one alternative device on site for both ventilation and intubation. The most common alternative ventilation device was the laryngeal mask airway (89%). The most common alternative intubating device was the surgical airway device (100%).

CONCLUSIONS

Irish departments of emergency medicine compare well with those in the UK and USA, when surveyed concerning difficult airway equipment. However, we believe that this situation could be further improved by training inexperienced healthcare providers in the use of the laryngeal mask airway and intubating laryngeal mask airway, by placing greater emphasis on the ready availability of capnography and by the increased use of portable difficult airway storage units.

Ultrasound image quality comparison between an inexpensive handheld emergency department (ED) ultrasound machine and a large mobile ED ultrasound system

Questions have been raised regarding image quality (IQ) provided by portable ultrasound (US) machines.

OBJECTIVES

To determine if a difference exists between images obtained with a common portable US machine and those obtained with a more expensive, larger US machine when comparing typical views used by emergency physicians.

METHODS

The authors performed a cross-sectional, blinded comparison of images from similar sonographic windows obtained on healthy models using a SonoSite 180 Plus and a General Electric (GE) 400 US machine. Both machines were optimized by company representatives. Images obtained included typical abdominal and vascular applications using the abdominal and linear transducers on each machine. All images were printed on identical high-resolution printers and then digitized using a bitmap format at 300 dots-per-inch resolution (RES). Images were then cropped, masked, and placed into random order comparing each view per model by a commercial Web design company (loracs.com). Three credentialed emergency physician sonologists, blinded to machine type, rated each image pair for RES, detail (DET), and total IQ as previously defined in the literature using a ten-point Likert scale; 10 was the best rating for each category. Paired t-test, 95% confidence intervals (95% CIs), and interobserver correlation were calculated.

RESULTS

A total of 49 image pairs were evaluated. Mean GE 400 RES, DET, and IQ scores were 6.8, 6.8, and 6.6, respectively. Corresponding SonoSite means were 6.3, 6.3, and 6.0, respectively. The difference of 0.5 (95% CI = 0.13 to 1.1) for DET was not statistically significant (p = 0.06). The differences of 0.5 (95% CI = 0.1 to 1.1) and 0.6 (95% CI = 0.2 to 1.2) for RES and IQ were statistically significant, with p = 0.01 and 0.01. There was good interobserver agreement (kappa = 0.71; 95% CI = 0.67 to 0.78).

CONCLUSIONS

A statistically significant difference was seen between GE 400 and SonoSite in IQ and RES, but not DET.

A calibrated paper clip is a reliable measure of two-point discrimination

OBJECTIVES

The primary objective of this study was to compare two different instruments for assessing digital nerve function; a secondary aim was to determine interobserver agreement among emergency physicians by using static two-point testing of digital nerve function.

METHODS

This was a prospective, blinded, observational study of static two-point discrimination involving healthy volunteers aged 18-59 years. The authors compared two instruments (paper clip set or Disk-Criminator) to assess two-point discrimination of the index and long fingers of the dominant hand. For each subject, the initial investigator and initial testing instrument were randomized. Two-point testing was conducted at 4, 5, and 6 mm by using six randomly selected stimuli (1 or 2 points) for each distal phalanx tested. The study was designed to detect a 25% difference in mean two-point distance with a power of 80%.

RESULTS

Seventy-five subjects were entered into the study, of which two were excluded. Interinstrument agreement for a given investigator ranged from 77% to 84% for absolute agreement and 98% to 100% within 2 mm. Weighted kappa values for interobserver differences of 2 mm or less was 0.79 to 1.00. There was no statistically significant difference between instruments.

CONCLUSIONS

Using a clinically relevant threshold of 2 mm, the authors found that a properly calibrated set of paper clips performed as well as the Disk-Criminator.

Frequency of incomplete abdominal aorta visualization by emergency department bedside ultrasound

OBJECTIVES

To determine how often emergency physicians (EPs) scanning the abdominal aorta (AA) of nonfasted emergency department (ED) patients are able to visualize the entire AA.

METHODS

The authors performed a retrospective study of patients receiving ultrasound (US) by EPs to rule out abdominal aortic aneurysm (AAA) at a suburban Level I ED. For patients being evaluated for possible AAA, EPs evaluated the entire length of the AA with US in short axis, making standard proximal, middle, and distal measurements. AAA was defined as dilation of the AA to >3 cm. Video of each US and data sheets were evaluated by a hospital-credentialed sonologist for visualization of the AA. Any portions of the AA not visualized were noted. If one third or more of the length of the AA was not seen, the examination was considered inadequate, allowing for potentially missing an AAA. Statistical analysis included descriptive statistics.

RESULTS

Ultrasounds of 207 patients were completed. In 35 patients (17%), a portion of the AA less than one third its length was not seen. In 17 patients (8%), a significant portion of the AA (at least one third its length) could not be visualized and therefore could have potentially concealed an AAA. In four patients, the AA could not be seen at all. There were 29 AAAs discovered (14%), and none were missed.

CONCLUSIONS

Significant portions of AA (at least one third of its length) were not visualized on bedside US in 8% of nonfasted patients; this rate is higher than radiology studies of fasted patients receiving US for evaluation of their aortas.

A review of emergency equipment carried and procedures performed by UK front line paramedics

OBJECTIVES

To assess which items of resuscitation equipment are carried on United Kingdom (UK) front line ambulances and what procedures paramedics are able to perform. To compare these findings with those of a previous survey in 1997.

METHOD

Postal survey to the chief executives of all the UK ambulance services and direct comparison with the data from 1997.

RESULTS

Nasopharyngeal airway usage (NPA) has increased (21-55%) and the laryngeal mask airway (LMA) (from 10 to 26%). No services employ the Combitube. 94% of services use a Hudson type trauma mask (increase of 17%). One service no longer allows its paramedics to deliver 12-15 l of oxygen. 68% of trust paramedics can perform needle thoracocentesis (increase of 35%). No paramedics perform chest drain insertion. All services have 14G intravenous cannulae available and 45% carry the intraosseous needle (increase of 30%). No services employ the MAST suit. There is an increase by 29% in the use of crystalloids and a decrease in the use of colloids of 22%. 23% of fluid resuscitation protocols are based upon the principles of hypotensive resuscitation. Spinal boards and extrication devices are used by 97% of services. The use of inflatable splints has decreased (38-23%). There has been a minor increase in the use of traction splints to 74% of services. The use of Entonox is universal. Nalbuphine (Nubain) is the most widely used opioid. The use of morphine/diamorphine has doubled to 10% with a further 26% to introduce their use. 29% of services have equipped some vehicles with automatic external defibrillators.

CONCLUSIONS

The equipment available to UK paramedics and procedures that they may perform continues to expand. There are still variations in the basic management of airway, breathing and circulation care and only some services are keeping up to date with current medical thinking, for example the increasing use of crystalloids and hypotensive resuscitation. It remains to be seen whether the widespread use of Nalbuphine as a first line analgesic may decrease as the use of natural strong opiates becomes more widespread.

Comparison of extraction devices for the removal of supraglottic foreign bodies

OBJECTIVE

By using a porcine model, the efficacy of various extraction devices for airway foreign body removal was examined.

METHODS

The upper airways of euthanized swine were occluded with a rubber ball, glass marble, or grape. A Magill forceps, a spongestick forceps, and a nasal trumpet attached to suction were used by test subjects for foreign body removal. Extraction success and time were recorded for each removal attempt. Satisfaction scores were recorded for each foreign body and device combination.

RESULTS

Seven paramedics, seven residents, and seven attending physicians participated. A total of 189 attempts were analyzed. Success rates for foreign body extraction with Magill and spongestick forceps were similar, with both devices superior to nasal trumpet (98% and 97% vs. 83%, respectively, p < 0.001). For successful ball removal attempts, the mean extraction time with spongestick forceps was less than those for both Magill forceps and nasal trumpet: 12.4 (95% confidence interval [CI], 10-14.7) versus 23.4 (95% CI, 16.3-30.3) and 21.2 (95% CI, 14.2-28.3) seconds, respectively. For marble removal, the mean extraction time with spongestick forceps also was less than Magill forceps and nasal trumpet: 10.8 (95% CI, 8.7-12.8) versus 18.4 (95% CI, 12.8 to 23.8) and 16.7 (95% CI, 12.6-20.8) seconds, respectively. For grape removal, the mean extraction times with both spongestick and Magill forceps were less than that of nasal trumpet: 11.8 (95% CI, 7.1 to 16.4) and 8.1 (95% CI, 6.8-9.4) versus 15.6 (95% CI 10-21.2) seconds, respectively. Subjects preferred the spongestick forceps for removal of the glass and rubber ball to the Magill forceps and nasal trumpet.

CONCLUSION

In this porcine model, the SF appeared to be the most efficient and preferred device for extracting the type of airway foreign body that is associated with fatal asphyxiation.

Ride quality evaluation of an actively-controlled stretcher for an ambulance

This study considers the subjective evaluation of ride quality during ambulance transportation using an actively-controlled stretcher (ACS). The ride quality of a conventional stretcher and an assistant driver's seat is also compared. Braking during ambulance transportation generates negative foot-to-head acceleration in patients and causes blood pressure to rise in the patient's head. The ACS absorbs the foot-to-head acceleration by changing the angle of the stretcher, thus reducing the blood pressure variation. However, the ride quality of the ACS should be investigated further because the movement of the ACS may cause motion sickness and nausea. Experiments of ambulance transportation, including rapid acceleration and deceleration, are performed to evaluate the effect of differences in posture of the transported subject on the ride quality; the semantic differential method and factor analysis are used in the investigations. Subjects are transported using a conventional stretcher with head forward, a conventional stretcher with head backward, the ACS, and an assistant driver's seat for comparison with transportation using a stretcher. Experimental results show that the ACS gives the most comfortable transportation when using a stretcher. Moreover, the reduction of the negative foot-to-head acceleration at frequencies below 0.2 Hz and the small variation of the foot-to-head acceleration result in more comfortable transportation. Conventional transportation with the head forward causes the worst transportation, although the characteristics of the vibration of the conventional stretcher seem to be superior to that of the ACS.