1
|
Czaja MP, Kraus CK, Phyo S, Olivieri P, Mederos DR, Puente I, Mohammed S, Berkeley RP, Slattery D, Gildea TH, Hardman C, Palmer B, Whitmill ML, Aluyen U, Pinnow JM, Young A, Eastin CD, Kester NM, Works KR, Pfeffer AN, Keller AW, Tobias A, Li B, Yorkgitis B, Saadat S, Langdorf MI. Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019: Injury Diagnosis Matrix, Incident Context, and Public Health Considerations. West J Emerg Med 2023; 24:552-565. [PMID: 37278791 DOI: 10.5811/westjem.58395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 01/25/2023] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION The epidemic of gun violence in the United States (US) is exacerbated by frequent mass shootings. In 2021, there were 698 mass shootings in the US, resulting in 705 deaths and 2,830 injuries. This is a companion paper to a publication in JAMA Network Open, in which the nonfatal outcomes of victims of mass shootings have been only partially described. METHODS We gathered clinical and logistic information from 31 hospitals in the US about 403 survivors of 13 mass shootings, each event involving greater than 10 injuries, from 2012-19. Local champions in emergency medicine and trauma surgery provided clinical data from electronic health records within 24 hours of a mass shooting. We organized descriptive statistics of individual-level diagnoses recorded in medical records using International Classification of Diseases codes, according to the Barell Injury Diagnosis Matrix (BIDM), a standardized tool that classifies 12 types of injuries within 36 body regions. RESULTS Of the 403 patients who were evaluated at a hospital, 364 sustained physical injuries-252 by gunshot wound (GSW) and 112 by non-ballistic trauma-and 39 were uninjured. Fifty patients had 75 psychiatric diagnoses. Nearly 10% of victims came to the hospital for symptoms triggered by, but not directly related to, the shooting, or for exacerbations of underlying conditions. There were 362 gunshot wounds recorded in the Barell Matrix (1.44 per patient). The Emergency Severity Index (ESI) distribution was skewed toward higher acuity than typical for an emergency department (ED), with 15.1% ESI 1 and 17.6% ESI 2 patients. Semi-automatic firearms were used in 100% of these civilian public mass shootings, with 50 total weapons for 13 shootings (Route 91 Harvest Festival, Las Vegas. 24). Assailant motivations were reported to be associated with hate crimes in 23.1%. CONCLUSION Survivors of mass shootings have substantial morbidity and characteristic injury distribution, but 37% of victims had no GSW. Law enforcement, emergency medical systems, and hospital and ED disaster planners can use this information for injury mitigation and public policy planning. The BIDM is useful to organize data regarding gun violence injuries. We call for additional research funding to prevent and mitigate interpersonal firearm injuries, and for the National Violent Death Reporting System to expand tracking of injuries, their sequelae, complications, and societal costs.
Collapse
Affiliation(s)
- Matthew P Czaja
- Ponce Health Sciences University School of Medicine, Ponce, Puerto Rico
| | - Chadd K Kraus
- Geisinger Emergency Medicine, Danville, Pennsylvania
| | - Su Phyo
- Touro University Nevada College of Osteopathic Medicine, Henderson, Nevada
| | | | - Dalier R Mederos
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida
| | - Ivan Puente
- Broward Health Medical Center, Division of Trauma and Critical Care Services, Fort Lauderdale, Florida
| | - Salman Mohammed
- Kirk Kerkorian School of Medicine at UNLV, Department of Emergency Medicine, Las Vegas, Nevada
| | - Ross P Berkeley
- Kirk Kerkorian School of Medicine at UNLV, Department of Emergency Medicine, Las Vegas, Nevada
| | - David Slattery
- Kirk Kerkorian School of Medicine at UNLV, Department of Emergency Medicine, Las Vegas, Nevada
| | - Thomas H Gildea
- St. Louise Regional Hospital, Department of Emergency Medicine, Gilroy, California
- Santa Clara Valley Medical Center, Department of Emergency Medicine, San Jose, California
| | - Claire Hardman
- Wright State University Boonshoft School of Medicine, Department of Surgery, Dayton, Ohio
| | - Brandi Palmer
- Kettering Health Main Campus, Trauma Research Program, Kettering, Ohio
| | - Melissa L Whitmill
- Kettering Health Main Campus, Division of Acute Care Surgery, Critical Care, and Trauma, Department of Surgery, Kettering, Ohio
| | - Una Aluyen
- Texas Tech University Health Sciences Center School of Medicine, Department of Emergency Medicine, Odessa, Texas
| | - Jeffery M Pinnow
- Medical Center Hospital, Department of Emergency Medicine, Odessa, Texas
| | - Amanda Young
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Carly D Eastin
- University of Arkansas for Medical Sciences, Department of Emergency Medicine, Little Rock, Arkansas
| | - Nurani M Kester
- University of Texas Health Science Center at San Antonio, Department of Emergency Medicine, San Antonio, Texas
| | - Kaitlyn R Works
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Andrew N Pfeffer
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, Tennessee
| | - Aleksander W Keller
- University of Pittsburgh Medical Center, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Adam Tobias
- University of Pittsburgh Medical Center, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Benjamin Li
- Denver Health, Department of Emergency Medicine, Denver, Colorado
| | - Brian Yorkgitis
- University of Florida College of Medicine, Division of Acute Care Surgery, Department of Surgery, Jacksonville, Florida
| | - Soheil Saadat
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Mark I Langdorf
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
2
|
Kraus CK, Langdorf MI, Czaja MP. Non-fatal injuries from Mass Shootings in the United States, 2012-2019: Epidemiology, Outcomes and Medical Resource Use. J Emerg Med 2023. [DOI: 10.1016/j.jemermed.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
|
3
|
Czaja MP, Kraus CK, Phyo S, Olivieri P, Mederos DR, Puente I, Mohammed S, Berkeley RP, Slattery D, Gildea TH, Hardman C, Palmer B, Whitmill ML, Aluyen U, Pinnow JM, Young A, Eastin CD, Kester NM, Works KR, Pfeffer AN, Keller AW, Tobias A, Li B, Yorkgitis B, Saadat S, Langdorf MI. Injury Characteristics, Outcomes, and Health Care Services Use Associated With Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019. JAMA Netw Open 2022; 5:e2213737. [PMID: 35622366 PMCID: PMC9142871 DOI: 10.1001/jamanetworkopen.2022.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Civilian public mass shootings (CPMSs) in the US result in substantial injuries. However, the types and consequences of these injuries have not been systematically described. OBJECTIVE To describe the injury characteristics, outcomes, and health care burden associated with nonfatal injuries sustained during CPMSs and to better understand the consequences to patients, hospitals, and society at large. DESIGN, SETTING, AND PARTICIPANTS This retrospective case series of nonfatal injuries from 13 consecutive CPMSs (defined as ≥10 injured individuals) from 31 hospitals in the US from July 20, 2012, to August 31, 2019, used data from trauma logs and medical records to capture injuries, procedures, lengths of stay, functional impairment, disposition, and charges. A total of 403 individuals treated in hospitals within 24 hours of the CPMSs were included in the analysis. Data were analyzed from October 27 to December 5, 2021. EXPOSURES Nonfatal injuries sustained during CPMSs. MAIN OUTCOMES AND MEASURES Injuries and diagnoses, treating services, procedures, hospital care, and monetary charges. RESULTS Among the 403 individuals included in the study, the median age was 33.0 (IQR, 24.5-48.0 [range, 1 to >89]) years, and 209 (51.9%) were women. Among the 386 patients with race and ethnicity data available, 13 (3.4%) were Asian; 44 (11.4%), Black or African American; 59 (15.3), Hispanic/Latinx; and 270 (69.9%), White. Injuries included 252 gunshot wounds (62.5%) and 112 other injuries (27.8%), and 39 patients (9.7%) had no physical injuries. One hundred seventy-eight individuals (53.1%) arrived by ambulance. Of 494 body regions injured (mean [SD], 1.35 [0.68] per patient), most common included an extremity (282 [57.1%]), abdomen and/or pelvis (66 [13.4%]), head and/or neck (65 [13.2%]), and chest (50 [10.1%]). Overall, 147 individuals (36.5%) were admitted to a hospital, 95 (23.6%) underwent 1 surgical procedure, and 42 (10.4%) underwent multiple procedures (1.82 per patient). Among the 252 patients with gunshot wounds, the most common initial procedures were general and trauma surgery (41 [16.3%]) and orthopedic surgery (36 [14.3%]). In the emergency department, 148 of 364 injured individuals (40.7%) had 199 procedures (1.34 per patient). Median hospital length of stay was 4.0 (IQR, 2.0-7.5) days; for 50 patients in the intensive care unit, 3.0 (IQR, 2.0-8.0) days (13.7% of injuries and 34.0% of admissions). Among 364 injured patients, 160 (44.0%) had functional disability at discharge, with 19 (13.3%) sent to long-term care. The mean (SD) charges per patient were $64 976 ($160 083). CONCLUSIONS AND RELEVANCE Civilian public mass shootings cause substantial morbidity. For every death, 5.8 individuals are injured. These results suggest that including nonfatal injuries in the overall burden of CPMSs may help inform public policy to prevent and mitigate the harm caused by such events.
Collapse
Affiliation(s)
- Matthew P. Czaja
- Ponce Health Sciences University School of Medicine, Ponce, Puerto Rico
| | | | - Su Phyo
- Touro University Nevada College of Osteopathic Medicine, Henderson
| | | | - Dalier R. Mederos
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Salman Mohammed
- Department of Emergency Medicine, University of Nevada, Las Vegas Kirk Kerkorian School of Medicine, Las Vegas
| | - Ross P. Berkeley
- Department of Emergency Medicine, University of Nevada, Las Vegas Kirk Kerkorian School of Medicine, Las Vegas
| | - David Slattery
- Department of Emergency Medicine, University of Nevada, Las Vegas Kirk Kerkorian School of Medicine, Las Vegas
| | - Thomas H. Gildea
- Department of Emergency Medicine, St Louise Regional Hospital, Gilroy, California
- Department of Emergency Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Claire Hardman
- Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Brandi Palmer
- Trauma Research Program, Kettering Medical Center, Kettering, Ohio
| | - Melissa L. Whitmill
- Division of Acute Care Surgery, Critical Care, and Trauma, Department of Surgery, Kettering Medical Center, Kettering, Ohio
| | - Una Aluyen
- Department of Emergency Medicine, Texas Tech University Health Sciences Center School of Medicine, Odessa
| | - Jeffery M. Pinnow
- Department of Emergency Medicine, Medical Center Hospital, Odessa, Texas
| | - Amanda Young
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Carly D. Eastin
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock
| | - Nurani M. Kester
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio
| | - Kaitlyn R. Works
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew N. Pfeffer
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aleksander W. Keller
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Adam Tobias
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Benjamin Li
- Department of Emergency Medicine, Denver Health, Denver, Colorado
| | - Brian Yorkgitis
- Division of Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Jacksonville
| | - Soheil Saadat
- Department of Emergency Medicine, School of Medicine, University of California, Irvine
| | - Mark I. Langdorf
- Department of Emergency Medicine, School of Medicine, University of California, Irvine
| |
Collapse
|
4
|
Stephenson GS, Langdorf MI. Testicular Torsion Appearance and Diagnosis on Computed Tomography of the Abdomen and Pelvis: Case Report. Clin Pract Cases Emerg Med 2022; 6:117-120. [PMID: 35701346 PMCID: PMC9197752 DOI: 10.5811/cpcem.2022.2.55315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/04/2022] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Testicular torsion, or the twisting of the spermatic cord compromising blood flow to the testis, is a urologic emergency with the potential to cause infertility in male patients. The diagnosis may be clinical or confirmed using imaging, with ultrasound being the modality of choice. CASE REPORT We present a case of right lower quadrant pain with radiation to the groin and right scrotum in a young male. A computed tomography of the abdomen and pelvis was ordered to assess for appendicitis, which showed a "whirl" sign on the inferior periphery of the images near the scrotum. The finding was not appreciated during the emergency department visit and the patient was discharged home. He returned 48 hours later due to continued pain and was ultimately diagnosed with testicular torsion via ultrasound and surgical pathology. CONCLUSION This is the first reported case to our knowledge identifying "whirl" sign for the diagnosis of testicular torsion. This finding was not appreciated by multiple clinicians during the initial patient presentation, highlighting the uncommon nature of the finding.
Collapse
|
5
|
Livingston JK, Gonzales S, Langdorf MI. Computed Tomography Appearance of the "Whirlpool Sign" in Ovarian Torsion. Clin Pract Cases Emerg Med 2021; 5:468-469. [PMID: 34813447 PMCID: PMC8610478 DOI: 10.5811/cpcem.2021.7.53317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/02/2021] [Indexed: 11/11/2022] Open
Abstract
Case Presentation A 28-year-old female presented to the emergency department complaining of right lower abdominal pain. A contrast-enhanced computed tomography (CT) was done, which showed a 15-centimeter right adnexal cyst with adjacent “whirlpool sign” concerning for right ovarian torsion. Transvaginal pelvic ultrasound (US) revealed a hemorrhagic cyst in the right adnexa, with duplex Doppler identifying arterial and venous flow in both ovaries. Laparoscopic surgery confirmed right ovarian torsion with an attached cystic mass, and a right salpingo-oophorectomy was performed given the mass was suspicious for malignancy. Discussion Ultrasound is the test of choice for diagnosis of torsion due to its ability to evaluate anatomy and perfusion. When ovarian pathology is on the patient’s right, appendicitis is high in the differential diagnosis, and CT may be obtained first. Here we describe a case where CT first accurately diagnosed ovarian torsion by demonstrating the whirlpool sign, despite an US that showed arterial flow to the ovary. Future studies should determine whether CT alone is sufficient to diagnose or exclude ovarian torsion.
Collapse
Affiliation(s)
- Joshua K Livingston
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Savannah Gonzales
- Cedars-Sinai Medical Center, Department of Obstetrics and Gynecology, Los Angeles, California
| | - Mark I Langdorf
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| |
Collapse
|
6
|
Phillips A, Lotfipour S, Langdorf MI. WestJEM Will No Longer Use the Term "Provider" to Refer to Physicians. West J Emerg Med 2021; 22:1023-1024. [PMID: 34546874 PMCID: PMC8463060 DOI: 10.5811/westjem.2021.8.54452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/18/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Andrew Phillips
- DHR Health, Departments of Emergency Medicine and Critical Care, Edinburg, Texas
| | - Shahram Lotfipour
- University of California, Irvine, Department of Emergency Medicine, Irvine, California.,Eisenhower Health, Department of Emergency Medicine, Rancho Mirage, California
| | | |
Collapse
|
7
|
Kraus CK, Langdorf MI. Firearms Injury Prevention, Emergency Medicine, and the Public's Health: A Call for Unity of Purpose. West J Emerg Med 2021; 22:457-458. [PMID: 34125013 PMCID: PMC8202984 DOI: 10.5811/westjem.2021.4.52861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Chadd K Kraus
- Geisinger, Department of Emergency Medicine, Danville, Pennsylvania
| | - Mark I Langdorf
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
8
|
Yu L, Baumann BM, Raja AS, Mower WR, Langdorf MI, Medak AJ, Anglin DR, Hendey GW, Nishijima D, Rodriguez RM. Blunt Traumatic Aortic Injury in the Pan-scan Era. Acad Emerg Med 2020; 27:291-296. [PMID: 31811732 DOI: 10.1111/acem.13900] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/21/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND In the era of frequent head-to-pelvis computed tomography (CT) for adult blunt trauma evaluation, we sought to update teachings regarding aortic injury by determining 1) the incidence of aortic injury; 2) the proportion of patients with isolated aortic injury (without other concomitant thoracic injury); 3) the clinical implications of aortic injury (hospital mortality, length of stay [LOS], and rate of surgical interventions); and 4) the screening value of traditional risk factors/markers (such as high-energy mechanism and widened mediastinum on chest x-ray [CXR]) for aortic injury, compared to newer criteria from the recently developed NEXUS Chest CT decision instrument (DI). METHODS We conducted a preplanned analysis of patients prospectively enrolled in the NEXUS Chest studies at 10 Level I trauma centers with the following inclusion criteria: age > 14 years, blunt trauma within 6 hours of ED presentation, and receiving chest imaging during ED trauma evaluation. RESULTS Of 24,010 enrolled subjects, 42 (0.17%, 95% confidence interval [CI] = 0.13% to 0.24%) had aortic injury. Most patients (79%, 95% CI = 64% to 88%) had an associated thoracic injury, with rib fractures, pneumothorax/hemothorax, and pulmonary contusion occurring most frequently. Compared to patients without aortic injury this cohort had similar mortality (9.5%, 95% CI = 3.8% to 22.1% vs. 5.8%, 95% CI = 5.4% to 6.3%), longer median hospital LOS (11 days vs. 3 days, p < 0.01), and higher median Injury Severity Score (29 vs. 5, p < 0.001). High-energy mechanism and widened mediastinum on CXR had low sensitivity for aortic injury (76% [95% CI = 62% to 87%] and 33% [95% CI = 21% to 49%], respectively), compared to the NEXUS Chest CT DI (sensitivity 100% [95% CI = 92% to 100%]). CONCLUSIONS Aortic injury is rare in adult ED blunt trauma patients who survive to receive imaging. Most ED aortic injury patients have associated thoracic injuries and survive to hospital discharge. Widened mediastinum on CXR and high-energy mechanism have relatively low screening sensitivity for aortic injury, but the NEXUS Chest DI detected all cases.
Collapse
Affiliation(s)
- Louis Yu
- Department of Emergency Medicine The University of California at San Francisco San Francisco CA
| | - Brigitte M. Baumann
- Department of Emergency Medicine Cooper Medical School of Rowan University Camden NJ
| | - Ali S. Raja
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MA
| | - William R. Mower
- Department of Emergency Medicine University of California at Los Angeles Los Angeles CA
| | - Mark I. Langdorf
- Department of Emergency Medicine University of California at Irvine Orange CA
| | - Anthony J. Medak
- University of California at San Diego School of Medicine La Jolla CA
| | - Deirdre R. Anglin
- Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles CA
| | - Gregory W. Hendey
- Department of Emergency Medicine University of California at Los Angeles Los Angeles CA
| | - Daniel Nishijima
- Department of Emergency Medicine University of California at Davis School of Medicine Orange CA
| | - Robert M. Rodriguez
- Department of Emergency Medicine The University of California at San Francisco San Francisco CA
| |
Collapse
|
9
|
Bizimungu R, Baumann BM, Raja AS, Mower WR, Langdorf MI, Medak AJ, Hendey GW, Nishijima D, Rodriguez RM. Thoracic Spine Fracture in the Panscan Era. Ann Emerg Med 2020; 76:143-148. [PMID: 31983495 DOI: 10.1016/j.annemergmed.2019.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 11/14/2019] [Accepted: 11/20/2019] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE In the current era of frequent chest computed tomography (CT) for adult blunt trauma evaluation, many minor injuries are diagnosed, potentially rendering traditional teachings obsolete. We seek to update teachings in regard to thoracic spine fracture by determining how often such fractures are observed on CT only (ie, not visualized on preceding trauma chest radiograph), the admission rate, mortality, and hospital length of stay of thoracic spine fracture patients, and how often thoracic spine fractures are clinically significant. METHODS This was a preplanned analysis of prospectively collected data from the NEXUS Chest CT study conducted from 2011 to 2014 at 9 Level I trauma centers. The inclusion criteria were older than 14 years, blunt trauma occurring within 6 hours of emergency department (ED) presentation, and chest imaging (radiography, CT, or both) during ED evaluation. RESULTS Of 11,477 enrolled subjects, 217 (1.9%) had a thoracic spine fracture; 181 of the 198 thoracic spine fracture patients (91.4%) who had both chest radiograph and CT had their thoracic spine fracture observed on CT only. Half of patients (49.8%) had more than 1 level of thoracic spine fracture, with a mean of 2.1 levels (SD 1.6 levels) of thoracic spine involved. Most patients (62%) had associated thoracic injuries. Compared with patients without thoracic spine fracture, those with it had higher admission rates (88.5% versus 47.2%; difference 41.3%; 95% confidence interval 36.3% to 45%), higher mortality (6.3% versus 4.0%; difference 2.3%; 95% confidence interval 0 to 6.7%), and longer length of stay (median 9 versus 6 days; difference 3 days; P<.001). However, thoracic spine fracture patients without other thoracic injury had mortality similar to that of patients without thoracic spine fracture (4.6% versus 4%; difference 0.6%; 95% confidence interval -2.5% to 8.6%). Less than half of thoracic spine fractures (47.4%) were clinically significant: 40.8% of patients received thoracolumbosacral orthosis bracing, 10.9% had surgery, and 3.8% had an associated neurologic deficit. CONCLUSION Thoracic spine fracture is uncommon. Most thoracic spine fractures are associated with other thoracic injuries, and mortality is more closely related to these other injuries than to the thoracic spine fracture itself. More than half of thoracic spine fractures are clinically insignificant; surgical intervention is uncommon and neurologic injury is rare.
Collapse
Affiliation(s)
- Remy Bizimungu
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - William R Mower
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California-Irvine, Irvine, CA
| | - Anthony J Medak
- University of California-San Diego School of Medicine, San Diego, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California-Davis School of Medicine, Davis, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA.
| |
Collapse
|
10
|
Klammer RM, Haydel MJ, Gallahue F, Bruno EC, Langdorf MI, Cheaito MA, Lotfipour S, Kazzi A. Program Visits and Residency Interviews. J Emerg Med 2019; 57:e133-e139. [DOI: 10.1016/j.jemermed.2019.04.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 04/22/2019] [Indexed: 10/26/2022]
|
11
|
Patel BH, Lew CO, Dall T, Anderson CL, Rodriguez R, Langdorf MI. Chest tube output, duration, and length of stay are similar for pneumothorax and hemothorax seen only on computed tomography vs. chest radiograph. Eur J Trauma Emerg Surg 2019; 47:939-947. [DOI: 10.1007/s00068-019-01198-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
|
12
|
Zigrossi D, Ralls G, Martel M, Rothrock SG, Langdorf MI, Cheaito MA, Lotfipour S, Kazzi A. Ranking Programs: Medical Student Strategies. J Emerg Med 2019; 57:e141-e145. [PMID: 31279639 DOI: 10.1016/j.jemermed.2019.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Selecting a training program is one of the most challenging choices an applicant to the Match has to make. DISCUSSION To make an informed decision, applicants should do a comprehensive research and carefully plan their upcoming steps. Factors that might influence the applicants' decision include geography, program reputation, specific areas of academic focus, subspecialty interests, university-versus community-based training, length of training and interest in combined programs. Such information can be gathered from published material, websites, and personal advice (from faculty, residents and advisors). This process is time-consuming and stressful. CONCLUSION Therefore, in this article we elaborate on the above to facilitate this process for applicants.
Collapse
Affiliation(s)
- Dominic Zigrossi
- Department of Emergency Medicine, Orlando Regional Medical Center, Florida State University School of Medicine, Orlando, Florida
| | - George Ralls
- Department of Emergency Medicine, Orlando Regional Medical Center, Florida State University School of Medicine, Orlando, Florida
| | - Marc Martel
- Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota
| | - Steven G Rothrock
- Department of Emergency Medicine, Orlando Regional Medical Center, Florida State University School of Medicine, Orlando, Florida
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California, Irvine, California
| | - Mohamad Ali Cheaito
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Shahram Lotfipour
- Department of Emergency Medicine, University of California, Irvine, California
| | - Amin Kazzi
- Department of Emergency Medicine, University of California, Irvine, California; Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
13
|
McCoy CE, Alrabah R, Weichmann W, Langdorf MI, Ricks C, Chakravarthy B, Anderson C, Lotfipour S. Feasibility of Telesimulation and Google Glass for Mass Casualty Triage Education and Training. West J Emerg Med 2019; 20:512-519. [PMID: 31123554 PMCID: PMC6526878 DOI: 10.5811/westjem.2019.3.40805] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 03/27/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction Our goal was to evaluate the feasibility and effectiveness of using telesimulation to deliver an emergency medical services (EMS) course on mass casualty incident (MCI) training to healthcare providers overseas. Methods We conducted a feasibility study to establish the process for successful delivery of educational content to learners overseas via telesimulation over a five-month period. Participants were registrants in an EMS course on MCI triage broadcast from University of California, Irvine Medical Simulation Center. The intervention was a Simple Triage and Rapid Treatment (START) course. The primary outcome was successful implementation of the course via telesimulation. The secondary outcome was an assessment of participant thoughts, feelings, and attitudes via a qualitative survey. We also sought to obtain quantitative data that would allow for the assessment of triage accuracy. Descriptive statistics were used to express the percentage of participants with favorable responses to survey questions. Results All 32 participants enrolled in the course provided a favorable response to all questions on the survey regarding their thoughts, feelings, and attitudes toward learning via telesimulation with wearable/mobile technology. Key barriers and challenges identified included dependability of Internet connection, choosing appropriate software platforms to deliver content, and intercontinental time difference considerations. The protocol detailed in this study demonstrated the successful implementation and feasibility of providing education and training to learners at an off-site location. Conclusion In this feasibility study, we were able to demonstrate the successful implementation of an intercontinental MCI triage course using telesimulation and wearable/mobile technology. Healthcare providers expressed a positive favorability toward learning MCI triage via telesimulation. We were also able to establish a process to obtain quantitative data that would allow for the calculation of triage accuracy for further experimental study designs.
Collapse
Affiliation(s)
- C Eric McCoy
- University of California, Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Rola Alrabah
- King Abdullah Bin Abdulaziz University Hospital, Department of Emergency Medicine, Riyadh, Saudi Arabia
| | - Warren Weichmann
- University of California, Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Mark I Langdorf
- University of California, Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Cameron Ricks
- University of California, Irvine School of Medicine, Department of Anesthesiology, Irvine, California
| | - Bharath Chakravarthy
- University of California, Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Craig Anderson
- University of California, Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Shahram Lotfipour
- University of California, Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
14
|
McCoy CE, Rahman A, Rendon JC, Anderson CL, Langdorf MI, Lotfipour S, Chakravarthy B. Randomized Controlled Trial of Simulation vs. Standard Training for Teaching Medical Students High-quality Cardiopulmonary Resuscitation. West J Emerg Med 2019; 20:15-22. [PMID: 30643596 PMCID: PMC6324716 DOI: 10.5811/westjem.2018.11.39040] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 10/11/2018] [Accepted: 11/14/2018] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Most medical schools teach cardiopulmonary resuscitation (CPR) during the final year in course curriculum to prepare students to manage the first minutes of clinical emergencies. Little is known regarding the optimal method of instruction for this critical skill. Simulation has been shown in similar settings to enhance performance and knowledge. We evaluated the comparative effectiveness of high-fidelity simulation training vs. standard manikin training for teaching medical students the American Heart Association (AHA) guidelines for high-quality CPR. METHODS This was a prospective, randomized, parallel-arm study of 70 fourth-year medical students to either simulation (SIM) or standard training (STD) over an eight-month period. SIM group learned the AHA guidelines for high-quality CPR via an hour session that included a PowerPoint lecture with training on a high-fidelity simulator. STD group learned identical content using a low-fidelity Resusci Anne® CPR manikin. All students managed a simulated cardiac arrest scenario with primary outcome based on the AHA guidelines definition of high-quality CPR (specifies metrics for compression rate, depth, recoil, and compression fraction). Secondary outcome was time to emergency medical services (EMS) activation. We analyzed data via Kruskal-Wallis rank sum test. Outcomes were performed on a simulated cardiac arrest case adapted from the AHA Advanced Cardiac Life Support (ACLS) SimMan® Scenario manual. RESULTS Students in the SIM group performed CPR that more closely adhered to the AHA guidelines of compression depth and compression fraction. Mean compression depth was 4.57 centimeters (cm) (95% confidence interval [CI] [4.30-4.82]) for SIM and 3.89 cm (95% CI [3.50-4.27]) for STD, p=0.02. Mean compression fraction was 0.724 (95% CI [0.699-0.751]) for SIM group and 0.679 (95% CI [0.655-0.702]) for STD, p=0.01. There was no difference for compression rate or recoil between groups. Time to EMS activation was 24.7 seconds (s) (95% CI [15.7-40.8]) for SIM group and 79.5 s (95% CI [44.8-119.6]) for STD group, p=0.007. CONCLUSION High-fidelity simulation training is superior to low-fidelity CPR manikin training for teaching fourth-year medical students implementation of high-quality CPR for chest compression depth and compression fraction.
Collapse
Affiliation(s)
- C Eric McCoy
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Asif Rahman
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Juan C Rendon
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Craig L Anderson
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Mark I Langdorf
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Shahram Lotfipour
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Bharath Chakravarthy
- University of California Irvine School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
15
|
Gottlieb M, Lotfipour S, Murphy L, Kraus CK, Langabeer JR, Langdorf MI. Scholarship in Emergency Medicine: A Primer for Junior Academics Part I: Writing and Publishing. West J Emerg Med 2018; 19:996-1002. [PMID: 30429932 PMCID: PMC6225948 DOI: 10.5811/westjem.2018.39283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/26/2018] [Accepted: 08/15/2018] [Indexed: 11/22/2022] Open
Abstract
The landscape of scholarly writing, publishing, and university promotion can be complex and challenging. Mentorship may be limited. To be successful it is important to understand the key components of writing and publishing. In this article, we provide expert consensus recommendations on four key challenges faced by junior faculty: writing the paper; selecting contributors and the importance of authorship order; journal selection and indexing; and responding to critiques. After reviewing this paper, the reader should have an enhanced understanding of these challenges and strategies to successfully address them.
Collapse
Affiliation(s)
- Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Shahram Lotfipour
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Linda Murphy
- University of California Irvine, UCI Science Library Reference Department, Irvine, California
| | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | | | - Mark I Langdorf
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
16
|
McCoy CE, Langdorf MI, Lotfipour S. American Heart Association/American Stroke Association Deletes Sections from 2018 Stroke Guidelines. West J Emerg Med 2018; 19:947-951. [PMID: 30429926 PMCID: PMC6225937 DOI: 10.5811/westjem.2018.9.39659] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/05/2018] [Accepted: 09/22/2018] [Indexed: 01/01/2023] Open
Abstract
The updated American Heart Association (AHA)/American Stroke Association (ASA) Guidelines for the Early Management of Patients with Acute Ischemic Stroke were published in January 2018.1 The purpose of the guidelines is to provide an up-to-date, comprehensive set of recommendations for clinicians caring for adult patients with acute arterial ischemic stroke in a single document. The guidelines detail new and updated recommendations that reflect and incorporate the most recent literature in the evaluation and management of acute ischemic stroke. Some sections of the latest guidelines have sparked debate in the medical community. Debate with regard to deciding the optimal diagnostic and treatment strategy for patients is healthy and anticipated with the release of new medical literature or recommendations. However, what is somewhat puzzling and unanticipated with the release of these new guidelines is that within two months of their release the AHA/ASA rescinded its recently released guidelines, publishing a "correction" in which several parts of the document have been deleted.2 An action such as this at the guideline level is unprecedented in recent history and has left stakeholders in the medical community somewhat confused as to the rationale for its occurrence. This article will inform the emergency medicine (EM) healthcare professional of the recent correction of the updated stroke guidelines, identify which sections have been removed (deleted), and will provide a brief summary of the pertinent updates (that have not been deleted) to the 2018 stroke guidelines that have particular relevance to the EM community.
Collapse
Affiliation(s)
- C Eric McCoy
- University of California Irvine School of Medicine, Department of Emergency Medicine, Orange, California
| | - Mark I Langdorf
- University of California Irvine School of Medicine, Department of Emergency Medicine, Orange, California
| | - Shahram Lotfipour
- University of California Irvine School of Medicine, Department of Emergency Medicine, Orange, California
| |
Collapse
|
17
|
Murphy LS, Kraus CK, Lotfipour S, Gottlieb M, Langabeer JR, Langdorf MI. Measuring Scholarly Productivity: A Primer for Junior Faculty. Part III: Understanding Publication Metrics. West J Emerg Med 2018; 19:1003-1011. [PMID: 30429933 PMCID: PMC6225941 DOI: 10.5811/westjem.2018.9.38213] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 09/24/2018] [Indexed: 11/11/2022] Open
Abstract
There are approximately 78 indexed journals in the specialty of emergency medicine (EM), making it challenging to determine which is the best option for junior faculty. This paper is the final component of a three-part series focused on guiding junior faculty to enhance their scholarly productivity. As an EM junior faculty's research career advances, the bibliometric tools and resources detailed in this paper should be considered when developing a publication submission strategy. The tenure and promotion decision process in many universities relies at least in part on these types of bibliometrics. This paper provides an understanding of new, alternative metrics that can be used to promote scientific progress in a transparent and timely manner.
Collapse
Affiliation(s)
- Linda S Murphy
- University of California-Irvine Libraries, Reference Department, Irvine, California
| | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | - Shahram Lotfipour
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | | | - Mark I Langdorf
- University of California Irvine Health School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
18
|
Langdorf MI. Predatory Publisher Attempts to Compromise WestJEM's Integrity. West J Emerg Med 2018; 19:767. [PMID: 30202485 PMCID: PMC6123088 DOI: 10.5811/westjem.2018.7.39918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Mark I Langdorf
- University of California, Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
19
|
Langabeer J, Gottlieb M, Kraus CK, Lotfipour S, Murphy LS, Langdorf MI. Scholarship in Emergency Medicine: A Primer for Junior Academics: Part II: Promoting Your Career and Achieving Your Goals. West J Emerg Med 2018; 19:741-745. [PMID: 30013714 PMCID: PMC6040906 DOI: 10.5811/westjem.2018.5.37539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/19/2018] [Accepted: 05/15/2018] [Indexed: 12/03/2022] Open
Abstract
Scholarship is an important component of success for academic emergency physicians. Scholarship can take many forms, but all require careful planning. In this article, we provide expert consensus recommendations for improving junior faculty’s scholarship in emergency medicine (EM). Specific focus is given to promoting your research career, obtaining additional training opportunities, networking in EM, and other strategies for strategically directing a long-term career in academic medicine.
Collapse
Affiliation(s)
| | | | - Chadd K Kraus
- Geisinger Health System, Department of Emergency Medicine, Danville, Pennsylvania
| | - Shahram Lotfipour
- University of California Irvine Health School of Medicine, Department of Emergency, Irvine, California
| | - Linda S Murphy
- University of California Irvine, UCI Science Library Reference Department, Irvine, California
| | - Mark I Langdorf
- University of California Irvine Health School of Medicine, Department of Emergency, Irvine, California
| |
Collapse
|
20
|
Langdorf MI, Anderson CL, Navarro RE, Strom S, McCoy CE, Youm J, Ypma-Wong MF. Comparing the Results of Written Testing for Advanced Cardiac Life Support Teaching Using Team-based Learning and the "Flipped Classroom" Strategy. Cureus 2018; 10:e2574. [PMID: 30013860 PMCID: PMC6039154 DOI: 10.7759/cureus.2574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objectives We sought to further determine whether cognitive test results changed for advanced cardiac life support (ACLS) taught in the team-based learning/flipped classroom format (TBL/FC) versus a lecture-based (LB) control. Methods We delivered 2010 ACLS to two classes of fourth-year medical students in the TBL/FC format (2015–2016), compared to three classes in the LB format (2012–2014). There were 27.5 hours of instruction for the TBL/FC model (TBL - 10.5 hours, podcasts - nine hours, small-group simulation - eight hours), and 20 hours (lectures - 12 hours, simulation - eight hours) in LB. We taught TBL for 13 cardiac cases while LB had none. Didactic content and seven simulated cases were the same in lecture (2012–2014) or in podcast formats (2015–2016). Testing was the same using 50 multiple-choice (MC) format questions, 20 rhythm-matching questions, and seven fill-in management of simulated cases. Results Some 468 students enrolled in the course 259 (55.4%) in the LB format in 2012–2014, and 209 (44.6%) in the TBL/FC format in 2015–2016. The scores for two out of three tests (MC and fill-in) increased with TBL/FC. Combined, median scores increased from 93.5% (IQR 90.6, 95.4) to 95.1% (92.5, 96.8, p = 0.0001). More students did not pass one of three tests with LB versus TBL/FC (24.7% versus 18.2%), and two or three parts of the test (8.1% versus 4.3%, p = 0.01). On the contrary, 77.5% passed all three with TBL/FC versus 67.2% with LB (change 10.3%, 95% CI 2.2%–18.2%). Conclusion TBL/FC teaching for ACLS improved written test results compared with the LB format.
Collapse
Affiliation(s)
- Mark I Langdorf
- Department of Emergency Medicine, University of California, Irvine, Irvine, USA
| | - Craig L Anderson
- Department of Emergency Medicine, University of California, Irvine, Irvine, USA
| | - Roman E Navarro
- Department of Emergency Medicine, University of California, Irvine, Irvine, USA
| | - Suzanne Strom
- Department of Anesthesiology and Perioperative Care, University of California, Irvine, Irvine, USA
| | - C Eric McCoy
- Department of Emergency Medicine, University of California, Irvine, Irvine, USA
| | - Julie Youm
- Medical Education, Univeristy of California, Irvine School of Medicine, Irvine, USA
| | - Mary F Ypma-Wong
- Graduate Division, University of California, Irvine, Irvine , USA
| |
Collapse
|
21
|
Murphy CE, Raja AS, Baumann BM, Medak AJ, Langdorf MI, Nishijima DK, Hendey GW, Mower WR, Rodriguez RM. Rib Fracture Diagnosis in the Panscan Era. Ann Emerg Med 2017; 70:904-909. [PMID: 28559032 DOI: 10.1016/j.annemergmed.2017.04.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/22/2017] [Accepted: 04/04/2017] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be accurate. We seek to determine rates of rib fracture observed on chest CT only; admission and mortality of patients with isolated rib fractures, rib fractures observed on CT only, and first or second rib fractures; and first or second rib fracture-associated great vessel injury. METHODS We conducted a planned secondary analysis of 2 prospectively enrolled cohorts of the National Emergency X-Radiography Utilization Study chest studies, which evaluated patients with blunt trauma who were older than 14 years and received chest imaging in the emergency department. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine outcomes. RESULTS Of 8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had rib fractures, and rib fractures were observed on chest CT only in 1,368 cases (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%; mean difference 42.9%; 95% confidence interval [CI] 41.4% to 44.4%) and mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than patients without rib fracture. The mortality of patients with rib fracture observed on chest CT only was not statistically significantly different from that of patients with fractures also observed on chest radiograph (4.8% versus 5.7%; mean difference -0.9%; 95% CI -3.1% to 1.1%). Patients with first or second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%) than patients with fractures of ribs 3 to 12, and the odds ratio of great vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4). CONCLUSION Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury.
Collapse
Affiliation(s)
- Charles E Murphy
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Anthony J Medak
- Department of Emergency Medicine, University of California-San Diego School of Medicine, San Diego, CA
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California-Irvine, Irvine, CA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California-Davis, Davis, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California-San Francisco Fresno Medical Education Program, Fresno, CA
| | - William R Mower
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA.
| |
Collapse
|
22
|
Moore N, Patel B, Zuabi N, Langdorf MI, Rodriguez RM. Feasibility of Informed Consent for Computed Tomography in Acute Trauma Patients. Acad Emerg Med 2017; 24:637-640. [PMID: 28145602 DOI: 10.1111/acem.13164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 01/19/2017] [Accepted: 01/22/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Computed tomography (CT) is common for trauma victims, but is usually done without informing patients of potential risks or obtaining informed consent. OBJECTIVE The objective of this study was to determine the feasibility of two elements (time and normal level of alertness) necessary for informed consent for CT in adult trauma patients. METHODS We conducted this prospective observational, two-phase cohort study at two urban, Level I trauma centers. In the first phase, we determined the median time needed to obtain informed consent for CT by performing sham consent on 11 injured patients at each site. In the second phase, we observed all adult trauma activation cases that presented during specified time blocks and recorded Glasgow Coma Scale (GCS) scores and the time available for consent (TAC) for CT-defined as the time between the end of the secondary trauma survey and when the patient left the resuscitation room to go to CT. We defined, a priori, feasible consent cases as those in which the patient had a GCS of 15 and a TAC greater than the median sham consent time at that site. RESULTS The median times for sham CT consent at the two sites were 3:36 and 2:09 minutes:seconds (range = 1:12-4:54). Of the 729 trauma patients enrolled during phase II, 646 (89%) had a CT scan, and of these 646 patients, 461 (71.4% [95% confidence interval = 67.8%- 74.7%]) met feasible consent criteria. Of the 185 patients who failed to meet feasible consent criteria, 171 (92.4%) had a GCS < 15, one (0.5%) had a TAC less than the sham consent time, and 13 (7.0%) had both. CONCLUSION We found that informed consent for CT was likely feasible in over two-thirds of acute, adult trauma patients.
Collapse
Affiliation(s)
- Nicole Moore
- Department of Emergency Medicine; University of California; San Francisco CA
| | - Bhavesh Patel
- Department of Emergency Medicine; University of California at Irvine; Irvine CA
| | - Nadia Zuabi
- Department of Emergency Medicine; University of California at Irvine; Irvine CA
| | - Mark I. Langdorf
- Department of Emergency Medicine; University of California at Irvine; Irvine CA
| | - Robert M. Rodriguez
- Department of Emergency Medicine; University of California; San Francisco CA
| |
Collapse
|
23
|
Murphy LS, Hansoti B, Langdorf MI. In reply to: "Not All Young Journals are Predatory". West J Emerg Med 2017; 18:319-323. [PMID: 29911816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023] Open
|
24
|
Boysen-Osborn M, Yanuck J, Mattson J, Toohey S, Wray A, Wiechmann W, Lahham S, Langdorf MI. Who to Interview? Low Adherence by U.S. Medical Schools to Medical Student Performance Evaluation Format Makes Resident Selection Difficult. West J Emerg Med 2016; 18:50-55. [PMID: 28116008 PMCID: PMC5226763 DOI: 10.5811/westjem.2016.10.32233] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/27/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction The Medical Student Performance Evaluation (MSPE) appendices provide a program director with comparative performance for a student’s academic and professional attributes, but they are frequently absent or incomplete. Methods We reviewed MSPEs from applicants to our emergency medicine residency program from 134 of 136 (99%) U.S. allopathic medical schools, over two application cycles (2012–13, 2014–15). We determined the degree of compliance with each of the five recommended MSPE appendices. Results Only three (2%) medical schools were compliant with all five appendices. The medical school information page (MSIP, appendix E) was present most commonly (85%), followed by comparative clerkship performance (appendix B, 82%), overall performance (appendix D, 59%), preclinical performance (appendix A, 57%), and professional attributes (appendix C, 18%). Few schools (7%) provided student-specific, comparative professionalism assessments. Conclusion Medical schools inconsistently provide graphic, comparative data for their students in the MSPE. Although program directors (PD) value evidence of an applicant’s professionalism when selecting residents, medical schools rarely provide such useful, comparative professionalism data in their MSPEs. As PDs seek to evaluate applicants based on academic performance and professionalism, rather than standardized testing alone, medical schools must make MSPEs more consistent, objective, and comparative.
Collapse
Affiliation(s)
- Megan Boysen-Osborn
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - Justin Yanuck
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - James Mattson
- University of California, Irvine, Department of Emergency Medicine, Irvine, California; New York Presbyterian Hospital, New York, New York
| | - Shannon Toohey
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - Alisa Wray
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - Warren Wiechmann
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - Shadi Lahham
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - Mark I Langdorf
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
25
|
Kesler KA, Langdorf MI, Burns MJ. Opioid Dependent Malingerer with Self-Induced Sepsis. West J Emerg Med 2016; 17:798-800. [PMID: 27833691 PMCID: PMC5102610 DOI: 10.5811/westjem.2016.9.31515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/15/2016] [Accepted: 09/21/2016] [Indexed: 11/11/2022] Open
Abstract
A 21-year-old woman was admitted to the emergency department (ED) with severe sepsis. Both the mechanism of infection and organisms discovered were unusual.
Collapse
Affiliation(s)
- Kelly A Kesler
- University of California, Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Mark I Langdorf
- University of California, Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Michael J Burns
- University of California, Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
26
|
Zuabi N, Patel B, Langdorf MI. U.S. Food and Drug Administration: Review for the Emergency Physician of Approval Process and Limitations. West J Emerg Med 2016; 17:741-746. [PMID: 27833682 PMCID: PMC5102601 DOI: 10.5811/westjem.2016.8.31197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/12/2016] [Accepted: 08/12/2016] [Indexed: 12/04/2022] Open
Affiliation(s)
- Nadia Zuabi
- University of California, Irvine, School of Medicine, Irvine, California
| | - Bhavesh Patel
- University of California, Irvine, School of Biological Sciences, Irvine, California
| | - Mark I Langdorf
- University of California, Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
27
|
Langdorf MI, Burns MJ, Rudkin S, Bradley D, Bridgeman TV, Gain M, Welbourne S. Emergency Department clinical algorithms: one academic medical centre's road to clinical excellence through collaborative practice. ACTA ACUST UNITED AC 2016. [DOI: 10.1258/jicp.2007.007177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Mark I Langdorf
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Michael J Burns
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Scott Rudkin
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Darlene Bradley
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Tania V Bridgeman
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Marla Gain
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Susan Welbourne
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA, USA
| |
Collapse
|
28
|
Affiliation(s)
- Mark I Langdorf
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - Michelle Lin
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| |
Collapse
|
29
|
Hansoti B, Langdorf MI, Murphy LS. Discriminating Between Legitimate and Predatory Open Access Journals: Report from the International Federation for Emergency Medicine Research Committee. West J Emerg Med 2016; 17:497-507. [PMID: 27625710 PMCID: PMC5017830 DOI: 10.5811/westjem.2016.7.30328] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 07/01/2016] [Accepted: 07/14/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction Open access (OA) medical publishing is growing rapidly. While subscription-based publishing does not charge the author, OA does. This opens the door for “predatory” publishers who take authors’ money but provide no substantial peer review or indexing to truly disseminate research findings. Discriminating between predatory and legitimate OA publishers is difficult. Methods We searched a number of library indexing databases that were available to us through the University of California, Irvine Libraries for journals in the field of emergency medicine (EM). Using criteria from Jeffrey Beall, University of Colorado librarian and an expert on predatory publishing, and the Research Committee of the International Federation for EM, we categorized EM journals as legitimate or likely predatory. Results We identified 150 journal titles related to EM from all sources, 55 of which met our criteria for OA (37%, the rest subscription based). Of these 55, 25 (45%) were likely to be predatory. We present lists of clearly legitimate OA journals, and, conversely, likely predatory ones. We present criteria a researcher can use to discriminate between the two. We present the indexing profiles of legitimate EM OA journals, to inform the researcher about degree of dissemination of research findings by journal. Conclusion OA journals are proliferating rapidly. About half in EM are legitimate. The rest take substantial money from unsuspecting, usually junior, researchers and provide no value for true dissemination of findings. Researchers should be educated and aware of scam journals.
Collapse
Affiliation(s)
- Bhakti Hansoti
- Johns Hopkins University, Department of Emergency Medicine, Baltimore, Maryland
| | - Mark I Langdorf
- University of California, Irvine, Department of Emergency Medicine, Irvine, California
| | - Linda S Murphy
- University of California, Irvine Libraries, Reference Department, Irvine, California
| |
Collapse
|
30
|
Zuabi N, Weiss LD, Langdorf MI. Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements. West J Emerg Med 2016; 17:245-51. [PMID: 27330654 PMCID: PMC4899053 DOI: 10.5811/westjem.2016.3.29705] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/23/2016] [Accepted: 03/13/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 was enacted to prevent hospitals from "dumping" or refusing service to patients for financial reasons. The statute prohibits discrimination of emergency department (ED) patients for any reason. The Office of the Inspector General (OIG) of the Department of Health and Human Services enforces the statute. The objective of this study is to determine the scope, cost, frequency and most common allegations leading to monetary settlement against hospitals and physicians for patient dumping. METHODS Review of OIG investigation archives in May 2015, including cases settled from 2002-2015 ( https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.asp ). RESULTS There were 192 settlements (14 per year average for 4000+ hospitals in the USA). Fines against hospitals and physicians totaled $6,357,000 (averages $33,435 and $25,625 respectively); 184/192 (95.8%, $6,152,000) settlements were against hospitals and eight against physicians ($205,000). Most common settlements were for failing to screen 144/192 (75%) and stabilize 82/192 (42.7%) for emergency medical conditions (EMC). There were 22 (11.5%) cases of inappropriate transfer and 22 (11.5%) more where the hospital failed to transfer. Hospitals failed to accept an appropriate transfer in 25 (13.0%) cases. Patients were turned away from hospitals for insurance/financial status in 30 (15.6%) cases. There were 13 (6.8%) violations for patients in active labor. In 12 (6.3%) cases, the on-call physician refused to see the patient, and in 28 (14.6%) cases the patient was inappropriately discharged. Although loss of Medicare/Medicaid funding is an additional possible penalty, there were no disclosures of exclusion of hospitals from federal funding. There were 6,035 CMS investigations during this time period, with 2,436 found to have merit as EMTALA violations (40.4%). However, only 192/6,035 (3.2%) actually resulted in OIG settlements. The proportion of CMS-certified EMTALA violations that resulted in OIG settlements was 7.9% (192/2,436). CONCLUSION Of 192 hospital and physician settlements with the OIG from 2002-15, most were for failing to provide screening (75%) and stabilization (42%) to patients with EMCs. The reason for patient "dumping" was due to insurance or financial status in 15.6% of settlements. The vast majority of penalties were to hospitals (95% of cases and 97% of payments). Forty percent of investigations found EMTALA violations, but only 3% of investigations triggered fines.
Collapse
Affiliation(s)
- Nadia Zuabi
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Larry D Weiss
- University of Maryland, Department of Emergency Medicine, Baltimore, Maryland
| | - Mark I Langdorf
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| |
Collapse
|
31
|
Rodriguez RM, Friedman B, Langdorf MI, Baumann BM, Nishijima DK, Hendey GW, Medak AJ, Raja AS, Mower WR. Pulmonary contusion in the pan-scan era. Injury 2016; 47:1031-4. [PMID: 26708426 DOI: 10.1016/j.injury.2015.11.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/14/2015] [Accepted: 11/25/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although pulmonary contusion (PC) is traditionally considered a major injury requiring intensive monitoring, more frequent detection by chest CT in blunt trauma evaluation may diagnose clinically irrelevant PC. OBJECTIVES We sought to determine (1) the frequency of PC diagnosis by chest CT versus chest X-ray (CXR), (2) the frequency of PC-associated thoracic injuries, and (3) PC patient clinical outcomes (mortality, length of stay [LOS], and need for mechanical ventilation), considering patients with PC seen on chest CT only (SOCTO) and isolated PC (PC without other thoracic injury). METHODS Focusing primarily on patients who had both CXR and chest CT, we conducted a pre-planned analysis of two prospectively enrolled cohorts with the following inclusion criteria: age >14 years, blunt trauma within 24h of emergency department presentation, and receiving CXR or chest CT during trauma evaluation. We defined PC and other thoracic injuries according to CT reports and followed patients through their hospital course to determine clinical outcomes. RESULTS Of 21,382 enrolled subjects, 8661 (40.5%) had both CXR and chest CT and 1012 (11.7%) of these had PC, making it the second most common injury after rib fracture. PC was SOCTO in 739 (73.0%). Most (73.5%) PC patients had other thoracic injury. PC patients had higher admission rates (91.9% versus 61.7%; mean difference 30.2%; 95% confidence interval [CI] 28.1-32.1%) and mortality (4.7% versus 2.0%: mean difference 2.8%; 95% CI 1.6-4.3%) than non-PC patients, but mortality was restricted to patients with other injuries (injury severity scores>10). Patients with PC SOCTO had low rates of associated mechanical ventilation (4.6%) and patients with isolated PC SOCTO had low mortality (2.6%), comparable to that of patients without PC. CONCLUSIONS PC is commonly diagnosed under current blunt trauma imaging protocols and most PC are SOCTO with other thoracic injury. Given that they are associated with low mortality and uncommon need for mechanical ventilation, isolated PC and PC SOCTO may be of limited clinical significance.
Collapse
Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, The University of California San Francisco, United States.
| | - Benjamin Friedman
- Department of Emergency Medicine, The University of California San Francisco, United States
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California Irvine, United States
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, United States
| | - Daniel K Nishijima
- Department of Emergency Medicine, The University of California Davis, United States
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California San Francisco Fresno Medical Education Program, United States
| | - Anthony J Medak
- Department of Emergency Medicine, University of California San Diego School of Medicine, United States
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, United States
| | - William R Mower
- Department of Emergency Medicine, University of California Los Angeles, United States
| |
Collapse
|
32
|
Shastry S, Langdorf MI. Electronic Vapor Cigarette Battery Explosion Causing Shotgun-like Superficial Wounds and Contusion. West J Emerg Med 2016; 17:177-80. [PMID: 26973744 PMCID: PMC4786238 DOI: 10.5811/westjem.2016.1.29410] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/07/2016] [Accepted: 01/13/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Siri Shastry
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| | - Mark I Langdorf
- University of California Irvine Medical Center, Department of Emergency Medicine, Orange, California
| |
Collapse
|
33
|
Boysen-Osborn M, Anderson CL, Navarro R, Yanuck J, Strom S, McCoy CE, Youm J, Ypma-Wong MF, Langdorf MI. Flipping the Advanced Cardiac Life Support Classroom with Team-based Learning: Comparison of Cognitive Testing Performance for Medical Students at the University of California, Irvine, United States. J Educ Eval Health Prof 2016; 13:11. [PMID: 26893399 PMCID: PMC4789594 DOI: 10.3352/jeehp.2016.13.11] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 02/14/2016] [Indexed: 05/12/2023]
Abstract
PURPOSE It aimed to find if written test results improved for advanced cardiac life support (ACLS) taught in flipped classroom/team-based Learning (FC/TBL) vs. lecture-based (LB) control in University of California-Irvine School of Medicine, USA. METHODS Medical students took 2010 ACLS with FC/TBL (2015), compared to 3 classes in LB (2012-14) format. There were 27.5 hours of instruction for FC/TBL model (TBL 10.5, podcasts 9, small-group simulation 8 hours), and 20 (12 lecture, simulation 8 hours) in LB. TBL covered 13 cardiac cases; LB had none. Seven simulation cases and didactic content were the same by lecture (2012-14) or podcast (2015) as was testing: 50 multiple-choice questions (MCQ), 20 rhythm matchings, and 7 fill-in clinical cases. RESULTS 354 students took the course (259 [73.1%] in LB in 2012-14, and 95 [26.9%] in FC/TBL in 2015). Two of 3 tests (MCQ and fill-in) improved for FC/TBL. Overall, median scores increased from 93.5% (IQR 90.6, 95.4) to 95.1% (92.8, 96.7, P=0.0001). For the fill-in test: 94.1% for LB (89.6, 97.2) to 96.6% for FC/TBL (92.4, 99.20 P=0.0001). For MC: 88% for LB (84, 92) to 90% for FC/TBL (86, 94, P=0.0002). For the rhythm test: median 100% for both formats. More students failed 1 of 3 tests with LB vs. FC/TBL (24.7% vs. 14.7%), and 2 or 3 components (8.1% vs. 3.2%, P=0.006). Conversely, 82.1% passed all 3 with FC/TBL vs. 67.2% with LB (difference 14.9%, 95% CI 4.8-24.0%). CONCLUSION A FC/TBL format for ACLS marginally improved written test results.
Collapse
Affiliation(s)
- Megan Boysen-Osborn
- Department of Emergency Medicine, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Craig L. Anderson
- Department of Emergency Medicine, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Roman Navarro
- Department of Emergency Medicine, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Justin Yanuck
- University of California-Irvine School of Medicine, Orange, CA, USA
| | - Suzanne Strom
- Department of Anesthesiology and Perioperative Care, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Christopher E. McCoy
- Department of Emergency Medicine, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Julie Youm
- Department of Emergency Medicine, University of California-Irvine School of Medicine, Orange, CA, USA
- Department of Microbiology and Molecular Genetic, University of California-Irvine School of Medicine, Orange, CA, USADivision of Educational Technology, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Mary Frances Ypma-Wong
- Department of Microbiology and Molecular Genetic, University of California-Irvine School of Medicine, Orange, CA, USADivision of Educational Technology, University of California-Irvine School of Medicine, Orange, CA, USA
- Department of Microbiology and Molecular Genetics, University of California-Irvine School of Medicine, Orange, CA, USA
| | - Mark I. Langdorf
- Department of Emergency Medicine, University of California-Irvine School of Medicine, Orange, CA, USA
- *Corresponding
| |
Collapse
|
34
|
Strom SL, Anderson CL, Yang L, Canales C, Amin A, Lotfipour S, McCoy CE, Osborn MB, Langdorf MI. Correlation of Simulation Examination to Written Test Scores for Advanced Cardiac Life Support Testing: Prospective Cohort Study. West J Emerg Med 2015; 16:907-12. [PMID: 26594288 PMCID: PMC4651592 DOI: 10.5811/westjem.2015.10.26974] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 09/18/2015] [Accepted: 10/19/2015] [Indexed: 01/08/2023] Open
Abstract
Introduction Traditional Advanced Cardiac Life Support (ACLS) courses are evaluated using written multiple-choice tests. High-fidelity simulation is a widely used adjunct to didactic content, and has been used in many specialties as a training resource as well as an evaluative tool. There are no data to our knowledge that compare simulation examination scores with written test scores for ACLS courses. Objective To compare and correlate a novel high-fidelity simulation-based evaluation with traditional written testing for senior medical students in an ACLS course. Methods We performed a prospective cohort study to determine the correlation between simulation-based evaluation and traditional written testing in a medical school simulation center. Students were tested on a standard acute coronary syndrome/ventricular fibrillation cardiac arrest scenario. Our primary outcome measure was correlation of exam results for 19 volunteer fourth-year medical students after a 32-hour ACLS-based Resuscitation Boot Camp course. Our secondary outcome was comparison of simulation-based vs. written outcome scores. Results The composite average score on the written evaluation was substantially higher (93.6%) than the simulation performance score (81.3%, absolute difference 12.3%, 95% CI [10.6–14.0%], p<0.00005). We found a statistically significant moderate correlation between simulation scenario test performance and traditional written testing (Pearson r=0.48, p=0.04), validating the new evaluation method. Conclusion Simulation-based ACLS evaluation methods correlate with traditional written testing and demonstrate resuscitation knowledge and skills. Simulation may be a more discriminating and challenging testing method, as students scored higher on written evaluation methods compared to simulation.
Collapse
Affiliation(s)
- Suzanne L Strom
- University of California Irvine School of Medicine, Department of Anesthesia and Perioperative Care, Irvine, California
| | - Craig L Anderson
- University of California Irvine School of Medicine, Department of Emergency
| | | | | | - Alpesh Amin
- University of California Irvine, Irvine, CaliforniaUniversity of California Irvine School of Medicine, Department of Medicine, Irvine, California
| | - Shahram Lotfipour
- University of California Irvine School of Medicine, Department of Emergency
| | - C Eric McCoy
- University of California Irvine School of Medicine, Department of Emergency
| | | | - Mark I Langdorf
- University of California Irvine School of Medicine, Department of Emergency
| |
Collapse
|
35
|
Raja AS, Lanning J, Gower A, Langdorf MI, Nishijima DK, Baumann BM, Hendey GW, Medak AJ, Mower WR, Rodriguez RM. Prevalence of Chest Injury With the Presence of NEXUS Chest Criteria: Data to Inform Shared Decisionmaking About Imaging Use. Ann Emerg Med 2015; 68:222-6. [PMID: 26607334 DOI: 10.1016/j.annemergmed.2015.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/15/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE The NEXUS chest decision instrument identifies a very-low-risk population of patients with blunt trauma for whom chest imaging can be avoided. However, it requires that all 7 National Emergency X-Ray Utilization Study (NEXUS) chest criteria be absent. To inform patient and physician shared decisionmaking about imaging, we describe the test characteristics of individual criteria of the NEXUS chest decision instrument and provide the prevalence of injuries when 1, 2, or 3 of the 7 criteria are present. METHODS We conducted this secondary analysis of 2 prospectively collected cohorts of patients with blunt trauma who were older than 14 years and enrolled in NEXUS chest studies between December 2009 and January 2012. Physicians at 9 US Level I trauma centers recorded the presence or absence of the 7 NEXUS chest criteria. We calculated test characteristics of each criterion and combinations of criteria for the outcome measures of major clinical injuries and thoracic injury observed on chest imaging. RESULTS We enrolled 21,382 patients, of whom 992 (4.6%) had major clinical injuries and 3,135 (14.7%) had thoracic injuries observed on chest imaging. Sensitivities of individual test characteristics ranged from 15% to 56% for major clinical injury and 14% to 53% for thoracic injury observed on chest imaging, with specificities varying from 71% to 84% for major clinical injury and 67% to 84% for thoracic injury observed on chest imaging. Individual criteria were associated with a prevalence of major clinical injury between 1.9% and 3.8% and of thoracic injury observed on chest imaging between 5.3% and 11.5%. CONCLUSION Patients with isolated NEXUS chest criteria have low rates of major clinical injury. The risk of major clinical injury for patients with 2 or 3 factors range from 1.7% to 16.6%, depending on the combination of criteria. Criteria-specific risks could be used to inform shared decisionmaking about the need for imaging by patients and their physicians.
Collapse
Affiliation(s)
- Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
| | - Jennifer Lanning
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Arian Gower
- Chicago Medical School at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California, Irvine, CA
| | | | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California, San Francisco Fresno Medical Education Program, San Francisco, CA
| | - Anthony J Medak
- Department of Emergency Medicine, University of California, San Diego School of Medicine, San Diego, CA
| | - William R Mower
- Department of Emergency Medicine, University of California, Los Angeles, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, CA
| |
Collapse
|
36
|
Langdorf MI, Zuabi N, Khan NA, Bithell C, Rowther AA, Reed K, Anderson CL, Lotfipour S, Rodriguez R. Yield and clinical predictors of thoracic spine injury from chest computed tomography for blunt trauma. West J Emerg Med 2015; 15:465-70. [PMID: 25035753 PMCID: PMC4100853 DOI: 10.5811/westjem.2014.4.20672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/10/2014] [Accepted: 04/16/2014] [Indexed: 11/18/2022] Open
Abstract
Introduction Cost and radiation risk have prompted intense examination of trauma patient imaging. A proposed decision instrument (DI) for the use of chest computed tomography (CT), (CCT) in blunt trauma patients includes thoracic spine (TS) tenderness, altered mental status (AMS) and distracting painful injury (DPI) as potential predictor variables. TS CT is a separate, costly study whose value is currently ill-defined. The objective of this study is to determine test characteristics of these predictor variables alone, and in combination, to derive a TS injury DI. Methods Prospective cohort study of blunt trauma patients age > 14 in a Level I Trauma Center who had either CCT or TS CT. Results Of 1,798 blunt trauma patients, 1,174 (65.3%) had CCT, and 46 (2.6%) had a TS CT at physician discretion. CCT identified 58 TS injuries in 1,220 patients (4.8%). For 1,032 patients without AMS, 18/35 had TS tenderness, for sensitivity of 51.4%, specificity 84.7%, positive (PPV) and negative predictive values (NPV) of 10.5% and 98.0%. Positive likelihood ratio (+LR) was 3.35, with negative (−LR) 0.57. Among the 58 TS injuries, 23 had AMS for sensitivity of 39.7%, with other test characteristics of 85.8%, 12.2%, 96.6%, with +LR 2.79 and −LR 0.70. Thirty-eight of 58 had DPI, for sensitivity 65.5%, with other test characteristics 65.7%, 8.7%, and 97.4%, with +LR 1.91 and −LR 0.52. Combining 3 predictor variables into a proposed DI found 56/58 injuries for test characteristics of 96.6% (95% CI 88.1–99.6%), 49.1% (46.1–52.0%), 8.6% (6.6–11.1%) and 99.7% (CI 98.7–100%), with +LR 1.90 (1.76–2.04) and −LR 0.07 (0.02–0.28). If validated, the DI would exclude 572/1,220 CCT patients from separate TS CT (46.9%, CI 44.1–49.7%), and 141/511 (27.6%, CI 23.8–31.7%) patients who actually had TS CT in our cohort. Medicare payment at our center for sagittal reconstructions of TS CT is $280 for professional plus technical charges ($3,312 per study). The DI, if validated, would save $39,000–$160,000 in TS imaging payments. Conclusion TS CT is low yield and costly. Patients who are alert, have no TS tenderness and no DPI have a very low likelihood of TS injury (NPV 99.7% 95% CI lower limit 98.7%) with –LR=0.07, 95% CI upper limit 0.28). Avoiding TS CT may save considerable charges and payments.
Collapse
Affiliation(s)
- Mark I Langdorf
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Nadia Zuabi
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Nooreen A Khan
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Chelsey Bithell
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Armaan A Rowther
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Karin Reed
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Craig L Anderson
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Shahram Lotfipour
- University of California Irvine, Department of Emergency Medicine, Irvine, California
| | - Robert Rodriguez
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| |
Collapse
|
37
|
Rodriguez RM, Langdorf MI, Nishijima D, Baumann BM, Hendey GW, Medak AJ, Raja AS, Allen IE, Mower WR. Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT). PLoS Med 2015; 12:e1001883. [PMID: 26440607 PMCID: PMC4595216 DOI: 10.1371/journal.pmed.1001883] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients. METHODS AND FINDINGS From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection. CONCLUSIONS We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.
Collapse
Affiliation(s)
- Robert M. Rodriguez
- Department of Emergency Medicine, University of California, San Francisco, California, United States of America
- * E-mail:
| | - Mark I. Langdorf
- Department of Emergency Medicine, University of California, Irvine, California, United States of America
| | - Daniel Nishijima
- Department of Emergency Medicine, University of California, Davis, California, United States of America
| | - Brigitte M. Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America
| | - Gregory W. Hendey
- Department of Emergency Medicine, UCSF Fresno Medical Education and Research, Fresno, California, United States of America
| | - Anthony J. Medak
- Department of Emergency Medicine, School of Medicine, University of California, San Diego, California, United States of America
| | - Ali S. Raja
- Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America
| | - Isabel E. Allen
- University of California, San Francisco, California, United States of America
| | - William R. Mower
- Department of Emergency Medicine, University of California, Los Angeles, California, United States of America
| |
Collapse
|
38
|
Langdorf MI, Medak AJ, Hendey GW, Nishijima DK, Mower WR, Raja AS, Baumann BM, Anglin DR, Anderson CL, Lotfipour S, Reed KE, Zuabi N, Khan NA, Bithell CA, Rowther AA, Villar J, Rodriguez RM. Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Ann Emerg Med 2015; 66:589-600. [PMID: 26169926 DOI: 10.1016/j.annemergmed.2015.06.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/23/2015] [Accepted: 06/01/2015] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. METHODS Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. RESULTS Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). CONCLUSION In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.
Collapse
Affiliation(s)
- Mark I Langdorf
- Department of Emergency Medicine, University of California-Irvine, Orange, CA.
| | - Anthony J Medak
- Department of Emergency Medicine, University of California-San Diego, La Jolla, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California-San Francisco, Fresno, Fresno, CA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California-Davis, Davis, CA
| | - William R Mower
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Deirdre R Anglin
- Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Craig L Anderson
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Shahram Lotfipour
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Karin E Reed
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Nadia Zuabi
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Nooreen A Khan
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Chelsey A Bithell
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Armaan A Rowther
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Julian Villar
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| |
Collapse
|
39
|
Perez MR, Rodriguez RM, Baumann BM, Langdorf MI, Anglin D, Bradley RN, Medak AJ, Mower WR, Hendey GW, Nishijima DK, Raja AS. Sternal fracture in the age of pan-scan. Injury 2015; 46:1324-7. [PMID: 25817167 DOI: 10.1016/j.injury.2015.03.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/08/2015] [Accepted: 03/05/2015] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVE Widespread chest CT use in trauma evaluation may increase the diagnosis of minor sternal fracture (SF), making former teaching about SF obsolete. We sought to determine: (1) the frequency with which SF patients are diagnosed by CXR versus chest CT under current imaging protocols, (2) the frequency of surgical procedures related to SF diagnosis, (3) SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture (ISF) and sternal fracture with other thoracic injury (SFOTI), and (4) the frequency and yield of cardiac contusion (CC) workups in SF patients. METHODS We analyzed charts and data of all SF patients enrolled from January 2009 to May 2013 in the NEXUS Chest and NEXUS Chest CT studies, two multi-centre observational cohorts of blunt trauma patients who received chest imaging for trauma evaluation. RESULTS Of the 14,553 patients in the NEXUS Chest and Chest CT cohorts, 292 (2.0%) were diagnosed with SF, and 94% of SF were visible on chest CT only. Only one patient (0.4%) had a surgical procedure related to SF diagnosis. Cardiac contusion was diagnosed in 7 (2.4%) of SF patients. SF patient mortality was low (3.8%) and not significantly different than the mortality of patients without SF (3.1%) [mean difference 0.7%; 95% confidence interval (CI) -1.0 to 3.5%]. Only 2 SF patient deaths (0.7%) were attributed to a cardiac cause. SFOTI patients had longer hospital stays but similar mortality to patients with ISF (mean difference 0.8%; 95% CI -4.7% to 12.0). CONCLUSIONS Most SF are seen on CT only and the vast majority are clinically insignificant with no change in treatment and low associated mortality. Workup for CC in SF patients is a low-yield practice. SF diagnostic and management guidelines should be updated to reflect modern CT-driven trauma evaluation protocols.
Collapse
Affiliation(s)
- Michael R Perez
- Department of Emergency Medicine, The University of California San Francisco, United States.
| | - Robert M Rodriguez
- Department of Emergency Medicine, The University of California San Francisco, United States
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, United States
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California Irvine, United States
| | - Deirdre Anglin
- Department of Emergency Medicine, Keck School of Medicine - University of Southern California, United States
| | - Richard N Bradley
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, United States
| | - Anthony J Medak
- University of California San Diego School of Medicine, Department of Emergency Medicine, United States
| | - William R Mower
- Department of Emergency Medicine, University of California Los Angeles, United States
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California San Francisco Fresno Medical Education Program, United States
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis, United States
| | - Ali S Raja
- Department of Emergency Medicine, Brigham and Women's Hospital/Harvard Medical School, United States
| |
Collapse
|
40
|
Hasegawa K, Cydulka RK, Sullivan AF, Langdorf MI, Nonas SA, Nowak RM, Wang NE, Camargo CA. Improved management of acute asthma among pregnant women presenting to the ED. Chest 2015; 147:406-414. [PMID: 25358070 DOI: 10.1378/chest.14-1874] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s. METHODS We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge. RESULTS Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04). CONCLUSIONS Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.
Collapse
Affiliation(s)
- Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Rita K Cydulka
- Department of Emergency Medicine, MetroHealth Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH
| | - Ashley F Sullivan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mark I Langdorf
- Department of Emergency Medicine, University of California Irvine Medical Center, Orange, CA
| | - Stephanie A Nonas
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University Hospital, Portland, OR
| | - Richard M Nowak
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
| | - Nancy E Wang
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
41
|
Connolly K, Beier L, Langdorf MI, Anderson CL, Fox JC. Ultrafest: a novel approach to ultrasound in medical education leads to improvement in written and clinical examinations. West J Emerg Med 2014; 16:143-8. [PMID: 25671024 PMCID: PMC4307699 DOI: 10.5811/westjem.2014.11.23746] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/22/2014] [Accepted: 11/25/2014] [Indexed: 11/16/2022] Open
Abstract
Introduction Our objective was to evaluate the effectiveness of hands-on training at a bedside ultrasound (US) symposium (“Ultrafest”) to improve both clinical knowledge and image acquisition skills of medical students. Primary outcome measure was improvement in multiple choice questions on pulmonary or Focused Assessment with Sonography in Trauma (FAST) US knowledge. Secondary outcome was improvement in image acquisition for either pulmonary or FAST. Methods Prospective cohort study of 48 volunteers at “Ultrafest,” a free symposium where students received five contact training hours. Students were evaluated before and after training for proficiency in either pulmonary US or FAST. Proficiency was assessed by clinical knowledge through written multiple-choice exam, and clinical skills through accuracy of image acquisition. We used paired sample t-tests with students as their own controls. Results Pulmonary knowledge scores increased by a mean of 10.1 points (95% CI [8.9–11.3], p<0.00005), from 8.4 to a posttest average of 18.5/21 possible points. The FAST knowledge scores increased by a mean of 7.5 points (95% CI [6.3–8.7] p<0.00005), from 8.1 to a posttest average of 15.6/21. We analyzed clinical skills data on 32 students. The mean score was 1.7 pretest and 4.7 posttest of 12 possible points. Mean improvement was 3.0 points (p<0.00005) overall, 3.3 (p=0.0001) for FAST, and 2.6 (p=0.003) for the pulmonary US exam. Conclusion This study suggests that a symposium on US can improve clinical knowledge, but is limited in achieving image acquisition for pulmonary and FAST US assessments. US training external to official medical school curriculum may augment students’ education.
Collapse
Affiliation(s)
- Kiah Connolly
- University of California, Irvine, School of Medicine, Irvine, California
| | - Lancelot Beier
- University of California, Irvine, School of Medicine, Irvine, California
| | - Mark I Langdorf
- University of California, Irvine, School of Medicine, Irvine, California
| | - Craig L Anderson
- University of California, Irvine, School of Medicine, Irvine, California
| | - John C Fox
- University of California, Irvine, School of Medicine, Irvine, California
| |
Collapse
|
42
|
Rodriguez RM, Baumann BM, Raja AS, Langdorf MI, Anglin D, Bradley RN, Medak AJ, Mower WR, Hendey GW. Diagnostic yields, charges, and radiation dose of chest imaging in blunt trauma evaluations. Acad Emerg Med 2014; 21:644-50. [PMID: 25039548 DOI: 10.1111/acem.12396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/09/2014] [Accepted: 01/13/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chest radiography (CXR) is the most common imaging in adult blunt trauma patient evaluation. Knowledge of the yields, attendant costs, and radiation doses delivered may guide effective chest imaging utilization. OBJECTIVES The objectives were to determine the diagnostic yields of blunt trauma chest imaging (CXR and chest computed tomography [CT]), to estimate charges and radiation exposure per injury identified, and to delineate assessment points in blunt trauma evaluation at which decision instruments for selective chest imaging would have the greatest effect. METHODS From December 2009 to January 2012, we enrolled patients older than 14 years who received CXR during blunt trauma evaluations at nine U.S. Level I trauma centers in this prospective, observational study. Thoracic injury seen on chest imaging and clinical significance of the injury were defined by a trauma expert panel. Yields of imaging were calculated, as well as mean charges and effective radiation dose (ERD) per injury. RESULTS Of 9,905 enrolled patients, 55.4% had CXR alone, 42.0% had both CXR and CT, and 2.6% had CT alone. The yields for detecting thoracic injury were CXR 8.4% (95% confidence intervals [CIs]) = 7.8% to 8.9%), chest CT 28.8% (95% CI = 27.5% to 30.2%), and chest CT after normal CXR 15.0% (95% CI = 13.9% to 16.2%). The mean charges and ERD (millisievert [mSv]) per injury diagnosis of CXR, chest CT, and chest CT after normal CXR were $3,845 (0.24 mSv), $10,597 (30.9 mSv), and $20,347 (59.3 mSv), respectively. The mean charges and ERD per clinically major thoracic injury diagnosis on chest CT after normal CXR were $203,467 and 593 mSv. CONCLUSIONS Despite greater diagnostic yield, chest CT entails substantially higher charges and radiation dose per injury diagnosed, especially when performed after a normal CXR. Selective chest imaging decision instruments should identify patients who require no chest imaging and patients who may benefit from chest CT after a normal CXR.
Collapse
Affiliation(s)
- Robert M. Rodriguez
- Department of Emergency Medicine; The University of California at San Francisco; San Francisco CA
| | - Brigitte M. Baumann
- The Department of Emergency Medicine; Cooper Medical School of Rowan University; Camden NJ
| | - Ali S. Raja
- The Department of Emergency Medicine; Brigham and Women's Hospital/Harvard Medical School; Boston MA
| | - Mark I. Langdorf
- The Department of Emergency Medicine; University of California at Irvine; Irvine CA
| | - Deirdre Anglin
- The Department of Emergency Medicine; Keck School of Medicine-University of Southern California; Los Angeles CA
| | - Richard N. Bradley
- The Department of Emergency Medicine; The University of Texas Health Science Center at Houston; Houston TX
| | - Anthony J. Medak
- The Department of Emergency Medicine; University of California at San Diego School of Medicine; San Diego CA
| | - William R. Mower
- The Department of Emergency Medicine; University of California at Los Angeles; Los Angeles CA
| | - Gregory W. Hendey
- The Department of Emergency Medicine; University of California at San Francisco Fresno Medical Education Program; Fresno CA
| |
Collapse
|
43
|
Abstract
BACKGROUND Medical student training and experience in cardiac arrest situations is limited. Traditional Advanced Cardiac Life Support (ACLS) teaching methods are largely unrealistic with rare personal experience as team leader. Yet Postgraduate Year 1 residents may perform this role shortly after graduation. PURPOSES We expanded our ACLS teaching to a "Resuscitation Boot Camp" where we taught 2010 ACLS to 19 pregraduation students in didactic (12 hours) and experiential (8 hours) format. METHODS Immediately before the course, we recorded students performing an acute coronary syndrome/ventricular fibrillation (VF) scenario. As a final test, we recorded the same scenario for each student. Primary outcomes were time to cardiopulmonary resuscitation (CPR) and defibrillation (DF). Secondary measures were total scenario score, dangerous actions, proportion of students voicing "ventricular fibrillation," 12-lead ST-elevation myocardial infarction (STEMI) interpretation, and care necessary for return of spontaneous circulation (ROSC). Two expert ACLS instructors scored both performances on a 121-point scale, with each student serving as their own control. We used t tests and McNemar tests for paired data with statistical significance at p<.05. RESULTS Before instruction, average time from arrest to CPR was 112 seconds and to first DF 3.01 minutes. Students scored 45±9/121 points and 9/19 (49%) performed dangerous actions. After instruction, time to CPR was 12 seconds (p=004) and to first DF 1.53 minutes (p=.03). Time to DF was delayed as students showed mastery of bag-valve-mask ventilation before DF. After instruction, students scored 97±4/121 points (p<.0001) with no dangerous actions. Before training, only 4 of 19 (21%) students performed both CPR and DF within 2 minutes, and 3 of these had ROSC. After training, 14 of 19 (74%) achieved CPR+DF≤2 minutes (p=.002), and all had ROSC. Before training, 5 of 19 (26%) students said "VF" and 4 of 19 obtained an ECG, but none identified STEMI. After training, corresponding performance was 13 of 19 "VF" (68%, p=021) and 100% ECG and STEMI identification (p<.05). CONCLUSIONS This course significantly improved knowledge and psychomotor skills. Critical actions required for resuscitation were much more common after training. ACLS training including high-fidelity simulation decreases time to CPR and DF and improves performance during resuscitation.
Collapse
Affiliation(s)
- Mark I Langdorf
- a Department of Emergency Medicine , University of California , Irvine, Orange , California , USA
| | | | | | | | | | | | | |
Collapse
|
44
|
Rodriguez RM, Anglin D, Langdorf MI, Baumann BM, Hendey GW, Bradley RN, Medak AJ, Raja AS, Juhn P, Fortman J, Mulkerin W, Mower WR. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013; 148:940-6. [PMID: 23925583 DOI: 10.1001/jamasurg.2013.2757] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Chest radiography (chest x-ray [CXR] and chest computed tomography [CT]) is the most common imaging in blunt trauma evaluation. Unnecessary trauma imaging leads to greater costs, emergency department time, and patient exposure to ionizing radiation. OBJECTIVE To validate our previously derived decision instrument (NEXUS Chest) for identification of blunt trauma patients with very low risk of thoracic injury seen on chest imaging (TICI). We hypothesized that NEXUS Chest would have high sensitivity (>98%) for the prediction of TICI and TICI with major clinical significance. DESIGN, SETTING, AND PARTICIPANTS From December 2009 to January 2012, we enrolled blunt trauma patients older than 14 years who received chest radiography in this prospective, observational, diagnostic decision instrument study at 9 US level I trauma centers. Prior to viewing radiographic results, physicians recorded the presence or absence of the NEXUS Chest 7 clinical criteria (age >60 years, rapid deceleration mechanism, chest pain, intoxication, abnormal alertness/mental status, distracting painful injury, and tenderness to chest wall palpation). MAIN OUTCOMES AND MEASURES Thoracic injury seen on chest imaging was defined as pneumothorax, hemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion or laceration seen on radiographs. An expert panel generated an a priori classification of clinically major, minor, and insignificant TICIs according to associated management changes. RESULTS Of 9905 enrolled patients, 43.1% had a single CXR, 42.0% had CXR and chest CT, 6.7% had CXR and abdominal CT (without chest CT), 5.5% had multiple CXRs without CT, and 2.6% had chest CT alone in the emergency department. The most common trauma mechanisms were motorized vehicle crash (43.9%), fall (27.5%), pedestrian struck by motorized vehicle (10.7%), bicycle crash (6.3%), and struck by blunt object, fists, or kicked (5.8%). Thoracic injury seen on chest imaging was seen in 1478 (14.9%) patients with 363 (24.6%) of these having major clinical significance, 1079 (73.0%) minor clinical significance, and 36 (2.4%) no clinical significance. NEXUS Chest had a sensitivity of 98.8% (95% CI, 98.1%-99.3%), a negative predictive value of 98.5% (95% CI, 97.6%.6-99.1%), and a specificity of 13.3% (95% CI, 12.6%-14.1%) for TICI. The sensitivity and negative predictive value for TICI with clinically major injury were 99.7% (95% CI, 98.2%-100.0%) and 99.9% (95% CI, 99.4%-100.0%), respectively. CONCLUSIONS AND RELEVANCE We have validated the NEXUS Chest decision instrument, which may safely reduce the need for chest imaging in blunt trauma patients older than 14 years.
Collapse
Affiliation(s)
- Robert M Rodriguez
- Department of Emergency Medicine, The University of California San Francisco School of Medicine, San Francisco General Hospital
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Langdorf MI, Lee S, Menchine MD. Financial implications for physicians accepting higher level of care transfers. West J Emerg Med 2013; 14:227-32. [PMID: 23687540 PMCID: PMC3656702 DOI: 10.5811/westjem.2011.10.6906] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 10/05/2012] [Accepted: 12/07/2011] [Indexed: 12/01/2022] Open
Abstract
Introduction: Higher-level-of-care (HLOC) transfers to tertiary care hospitals are common. While this has been shown profitable for hospitals, the impact on physicians has not been described. Community medical center call panels continue to erode, in part due to the perception that patients needing transfer are underinsured. Surveys show that the problematic specialties to maintain call panels in community hospitals are neurosurgery, otolaryngology, plastic surgery, orthopedics and ophthalmology. This places greater stress on tertiary care hospitals' physicians. The objective of this study is to describe the financial consequences to physicians who care for HLOC transfers across specialties and compare these with all patients from each specialty and specialty-specific national reimbursement benchmarks. Methods: Financial data were obtained for all HLOC transfers to a single tertiary care center from January 2007 through March 2008. Work relative value unit (RVU) and reimbursement were taken from a centralized professional fee billing office. National benchmarks for reimbursement per RVU were calculated from the 2006 Medical Group Management Association (MGMA) Compensation and Production Survey. Results: In this period 570 patients were transferred, 319 (55.9%) through the emergency department (ED). Reimbursement per RVU varied from a high of $74.93 for neurosurgery to $25.91 for family medicine. Reimbursement to emergency medicine (EM) for HLOC patients was 16% above the average reimbursement per RVU for all ED patients ($50.5 vs. $43.7). Similarly, neurosurgery reimbursement per RVU was 22% above the reimbursement per RVU for all patients ($74.93 vs. $61.27). The remainder of specialties was reimbursed less ($25.91 vs $69.60) per RVU for HLOC patients than for all of their patients at this center. All specialties at this site were reimbursed less for each HLOC patient than national average reimbursement for all patients in each specialty. Conclusion: Average professional fee reimbursement for HLOC patients was higher for EM and neurosurgery than for all other patients in these specialties at this site, but lower for the rest of the specialties. Compared to the national benchmarks, this site had an overall lower reimbursement per RVU for all specialties, reflecting a poorer patient mix. At this site HLOC transfers patients are financially advantageous for EM and neurosurgery.
Collapse
Affiliation(s)
- Mark I Langdorf
- University of California Irvine, Department of Emergency Medicine, Orange, California
| | | | | |
Collapse
|
46
|
Calkins TR, Miller K, Langdorf MI. Success and Complication Rates with Prehospital Placement of an Esophageal-Tracheal Combitube as a Rescue Airway. Prehosp Disaster Med 2012; 21:97-100. [PMID: 16770999 DOI: 10.1017/s1049023x00003423] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction:Previous studies have proven the success of the EsophagealTracheal Combitube (ETC) as a primary airway, but not as a rescue airway.Objective:The object of this study was to observe success and complication rates of paramedic placement of an ETC as a rescue airway, and to compare success rates with endotracheal tube (ETT) intubation. The primary outcome indicator was placement with successful ventilation. Complication rates, esophageal placement, and return of spontaneous circulation (ROSC) were secondary measures.Methods:A retrospective review of the records of patients who had ETC attempts by Emergency Medical Services (EMS) was conducted for a period of three years. Complications were defined a priori. The ETC is used primarily as rescue airway for a failed attempt at an endotracheal tube (ETT) intubation. A control group for ETT placements was drawn from the EMS quality assurance (QA) database for the same period.Results:Esophageal-Tracheal Combitube insertion was attempted on 162 patients, of which, 113 (70%) were successful, 46 (28%) failed, and the outcome of three (2%) was not recorded. Inability to place the ETC occurred in 29 (18%) patients, and accounted for 48% (22/46) of failures. The use of the ETC caused dental trauma in one patient, and one placement of the ETC was related to the onset of subcutaneous emphysema. Blood in the ETC from active upper gatrointestinal bleeding occurred in nine patients (6%), and four tubes (3%) became dislodged en route to the hospital. The a priori complication rate was 44/162 (27%). Inability to determine placement of the ETC due to emesis from both ports occurred in 21 cases. Combining these problems with the a priori complications, the overall rate was 40% (65/162). EsophagealTracheal Combitube location was noted in a subset of 90 charts, of which, 76 (84%) were esophageal, and 14 (16%) were tracheal. Thirteen of 126 (10%) patients in cardiac arrest had return of spontaneous circulation (ROSC) in the field after placement of the ETC. An ETT was attempted in 128 control patients, of which, 107 (84%) were successful, 21 (16%) failed (odds ratio (OR) for ETT vs. ETC = 2.1; 95% CI = 1.12–3.86).Conclusion:Despite a low ROSC rate, the complication and success rates of ETC are acceptable for a rescue airway device. Tracheal placement of the Combitube is uncommon, but requires fail-safe discrimination. Similar to previous reports, the success ratio for ETT was greater than for the ETC.
Collapse
Affiliation(s)
- Thomas R Calkins
- Department of Emergency Medicine, University of California-Irvine, California 92868, USA
| | | | | |
Collapse
|
47
|
Rudkin SE, Kahn CA, Oman JA, Dolich MO, Lotfipour S, Lush S, Gain M, Firme C, Anderson CL, Langdorf MI. Prospective correlation of arterial vs venous blood gas measurements in trauma patients. Am J Emerg Med 2011; 30:1371-7. [PMID: 22169587 DOI: 10.1016/j.ajem.2011.09.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 09/23/2011] [Accepted: 09/23/2011] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The objective of this study is to assess if venous blood gas (VBG) results (pH and base excess [BE]) are numerically similar to arterial blood gas (ABG) in acutely ill trauma patients. METHODS We prospectively correlated paired ABG and VBG results (pH and BE) in adult trauma patients when ABG was clinically indicated. A priori consensus threshold of clinical equivalence was set at ± less than 0.05 pH units and ± less than 2 BE units. We hypothesized that ABG results could be predicted by VBG results using a regression equation, derived from 173 patients, and validated on 173 separate patients. RESULTS We analyzed 346 patients and found mean arterial pH of 7.39 and mean venous pH of 7.35 in the derivation set. Seventy-two percent of the paired sample pH values fell within the predefined consensus equivalence threshold of ± less than 0.05 pH units, whereas the 95% limits of agreement (LOAs) were twice as wide, at -0.10 to 0.11 pH units. Mean arterial BE was -2.2 and venous BE was -1.9. Eighty percent of the paired BE values fell within the predefined ± less than 2 BE units, whereas the 95% LOA were again more than twice as wide, at -4.4 to 3.9 BE units. Correlations between ABG and VBG were strong, at r(2) = 0.70 for pH and 0.75 for BE. CONCLUSION Although VBG results do correlate well with ABG results, only 72% to 80% of paired samples are clinically equivalent, and the 95% LOAs are unacceptably wide. Therefore, ABG samples should be obtained in acutely ill trauma patients if accurate acid-base status is required.
Collapse
Affiliation(s)
- Scott E Rudkin
- Department of Emergency Medicine, University of California, Irvine, CA 92868, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Fox JC, Boysen M, Gharahbaghian L, Cusick S, Ahmed SS, Anderson CL, Lekawa M, Langdorf MI. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477-82. [PMID: 21569167 DOI: 10.1111/j.1553-2712.2011.01071.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT. METHODS This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery. RESULTS The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%). CONCLUSION In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.
Collapse
Affiliation(s)
- J Christian Fox
- Department of Emergency Medicine and Department of Surgery (JCF, MB, SSA, CLA, ML, MIL), University of California at Irvine, Orange, CA.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Simonian SM, Lotfipour S, Wall C, Langdorf MI. Challenging the superiority of amiodarone for rate control in Wolff-Parkinson-White and atrial fibrillation. Intern Emerg Med 2010; 5:421-6. [PMID: 20437113 DOI: 10.1007/s11739-010-0385-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 03/26/2010] [Indexed: 11/28/2022]
Abstract
The objective of this review is to explore and challenge the superiority of amiodarone for rate control in Wolff-Parkinson-White syndrome and concomitant atrial fibrillation (WPW-AF). The current recommendation for pharmacological treatment of this condition is amiodarone. A review of the past 25 years of literature finds several studies that identify a small risk of ventricular fibrillation secondary to amiodarone administration for rate control in WPW-AF. Additionally, the literature supports the safe and effective use of procainamide for rate control in WPW-AF. This review concludes that amiodarone is not superior to procainamide in rate control for WPW-AF, and may be dangerous.
Collapse
Affiliation(s)
- Sharis M Simonian
- Department of Emergency Medicine, University of California-Irvine School of Medicine, 101 The City Drive, Orange, CA 92868, USA
| | | | | | | |
Collapse
|
50
|
Langdorf MI, Wei E, Ghobadi A, Rudkin SE, Lotfipour S. Echocardiography to supplement stress electrocardiography in emergency department chest pain patients. West J Emerg Med 2010; 11:379-83. [PMID: 21079713 PMCID: PMC2967693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Revised: 02/21/2010] [Accepted: 03/24/2010] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Chest pain (CP) patients in the Emergency Department (ED) present a diagnostic dilemma, with a low prevalence of coronary disease but grave consequences with misdiagnosis. A common diagnostic strategy involves ED cardiac monitoring while excluding myocardial necrosis, followed by stress testing. We sought to describe the use of stress echocardiography (echo) at our institution, to identify cardiac pathology compared with stress electrocardiography (ECG) alone. METHODS Retrospective cohort study of 57 urban ED Chest Pain Unit (CPU) patients from 2002-2005 with stress testing suggesting ischemia. Our main descriptive outcome was proportion and type of discordant findings between stress ECG testing and stress echo. The secondary outcome was whether stress echo results appeared to change management. RESULTS Thirty-four of 57 patients [59.7%, 95% confidence interval (CI) 46.9-72.4%] had stress echo results discordant with stress ECG results. The most common discordance was an abnormal stress ECG with a normal stress echo (n=17/57, 29.8%, CI 17.9-41.7%), followed by normal stress ECG but with reversible regional wall-motion abnormality on stress echo (n = 10/57, 17.5%, CI 7.7-27.4%). The remaining seven patients (12.3%, CI 3.8-20.8%) had non-diagnostic stress ECG due to sub-maximal effort. Stress echo showed reversible wall-motion abnormality in two, and five were normal. Twenty-five of the 34 patients (73.5%, CI 56.8-85.4%) with discordant results had a different diagnostic strategy than predicted from their stress ECG alone. CONCLUSION The addition of echo to stress ECG testing in ED CPU patients altered diagnosis in 34/57 (59.7%, CI 46.9-72.4%) patients, and appeared to change management in 25/57 (43.9%, CI 31.8-57.6%) patients.
Collapse
Affiliation(s)
- Mark I. Langdorf
- University of California, Irvine, Department of Emergency Medicine, Irvine, CA,Address for Correspondence: Mark Langdorf, MD, MHPE, Department of Emergency Medicine, University of California, Irvine, 101 The City Dr., Orange, CA 92868.
| | - Eric Wei
- University of Michigan, Ann Arbor, MI
| | - Ali Ghobadi
- University of California, Irvine, Department of Emergency Medicine, Irvine, CA
| | - Scott E. Rudkin
- University of California, Irvine, Department of Emergency Medicine, Irvine, CA
| | - Shahram Lotfipour
- University of California, Irvine, Department of Emergency Medicine, Irvine, CA
| |
Collapse
|