A Retrospective Review of Emergency Department Visits That May Be Appropriate for Management in Non-Emergency Settings.

Background: Emergency departments (EDs) continue to struggle with overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for non-emergent medical issues or injuries that could readily be handled in a primary care setting. We analyzed encounters in the ED at the Brooke Army Medical Center-the largest hospital in the Department of Defense-to determine the percentage of visits that could potentially be managed in a lower cost, appointment-based setting.

Changes in Emergency Department Volumes at the Largest U.S. Military Hospital During the COVID-19 Pandemic.

Introduction: The coronavirus-2019 (COVID-19) pandemic has significantly impacted global healthcare delivery. Brooke Army Medical Center (BAMC) is the DoD's largest hospital and a critical platform for maintaining a ready medical force. We compare temporal trends in patient volumes and characteristics in the BAMC emergency department (ED) before versus during the pandemic.

The Ultimate Poker Face: A Case Report of Facial Diplegia, a Guillain-Barré Variant.

Introduction: Facial diplegia, a rare variant of Guillain-Barré syndrome (GBS), is a challenging diagnosis to make in the emergency department due to its resemblance to neurologic Lyme disease.

Case Report: We present a case of a 27-year-old previously healthy man who presented with bilateral facial paralysis.

Discussion: Despite the variance in presentation, the recommended standard of practice for diagnostics (cerebrospinal fluid albumin-cytological dissociation) and disposition (admission for observation, intravenous immunoglobulin, and serial negative inspiratory force) of facial diplegia are the same as for other presentations of GBS.

To tPA or Not to tPA: Two Medical-Legal Misadventures of Diagnosing a Cerebrovascular Accident as a Stroke Mimic.

We present two recent successfully litigated malpractice cases in which patients with cerebrovascular accidents were misdiagnosed as stroke mimics. The first was diagnosed as a hemiplegic migraine, which occurs in only 0.01% of the population.

Patient with a Subarachnoid Headache.

Subarachnoid hemorrhage (SAH) is a life-threatening cause of headache. The diagnostic approach to this entity continues to evolve with a recent questioning of the classic workup of computed tomography and lumbar puncture. We report a risk management case of a patient with a missed SAH resulting in a fatal outcome.

Prehospital Administration of Antibiotic Prophylaxis for Open Combat Wounds in Afghanistan: 2013-2014.

Background: Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers.

Routine Screening Laboratory Studies for Nonheat Stroke Field Heat Injuries Are Unnecessary: A Retrospective Review.

Background: Heat injuries are common in the military training environment. Base policies often mandate that heat causalities require evaluation at a higher level of care, which comes at significant use of resources. Laboratory studies are often ordered routinely, but their utility is unclear at this time.

Emergency Department Wounds Managed by Combat Medics: A Case Series.

Background: Combat medics are an integral part of their unit helping to conserve the fighting strength. Minor wounds are a common problem in the deployed settings that affect a soldier's ability to partake in operations. While the medics often manage wound care, there is very little data on the outcomes.

A Soldier With an Exertional Heat Injury, Ischemic-Appearing Electrocardiogram, and Elevated Troponins: A Clinical Case Report.

Heat injuries are a common occurrence in the military training setting due to both the physically demanding nature of the training and the environments in which we train. Testing is often done after the diagnosis of a heat injury to screen for abnormalities. We present the case of a 20-year-old male Soldier with an abnormal electrocardiogram (ECG) with a possible injury pattern and an elevated troponin level.

Emergency Department Management Of Acute Infective Endocarditis.

Infective endocarditis has a high rate of mortality, and most patients suspected of having the disease will require hospital admission. This review examines the literature as it pertains specifically to emergency clinicians who must maintain vigilance for risk factors and obtain a thorough history, including use of intravenous drugs, in order to guide the workup and treatment. Properly obtained cultures are critical during the evaluation, as they direct the course of antibiotic therapy.

Clinical quality management in the combat zone: the good, the bad, and the unintended consequences.

Clinical quality management (CQM) is a fixture of modern U.S. healthcare to include fixed military medical treatment facilities.

Postdischarge secobarbital after ED migraine treatment decreases pain and improves resolution.

Objective: The objective of the study was to determine whether the addition of postdischarge oral secobarbital to standard emergency department (ED) migraine headache therapy improves pain relief and headache resolution compared with placebo.

Setting: The setting is an urban ED with 70 000 yearly visits.

Methods: This is an Institutional Review Board-approved, randomized, nonconsecutive, double-blinded, concealed, and placebo-controlled clinical trial.

Diagnostic and predictive values of thirst, angiotensin II, and vasopressin during trauma resuscitation.

Background: Thirst perception involves neurochemical signals attributed to acute elevation of arginine vasopressin (AVP) and angiotensin II (AT2) levels, and may accompany acute hemorrhage.

Objective: To determine whether thirst or plasma AVP or AT2 levels predict hemorrhagic shock, injury severity, or outcome in trauma patients at initial presentation.

Methods: This was a prospective case series of adult subjects presenting as trauma activations to an urban level I trauma center.

Malpractice cases in wound care and a legal concept: special defense.

There is no doubt that in today's practice of emergency medicine it is imperative to be familiar with how the law relates to administrative and clinical practice. It is my pleasure to announce, as section editor, the new Legal Medicine section of the Western Journal of Emergency Medicine. It is anticipated that the articles will cover a variety of areas and cases in the law.

The retrospective prevalence of community-acquired methicillin-resistant Staphylococcus aureus in soft tissue abscesses at two military level I trauma centers.

Study Objective: Many studies have shown that community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) is a very prevalent organism. However, no data have been published to date with regard to CAMRSA prevalence in patients presenting to the emergency department (ED) of a military medical facility. Our objective is to estimate the period prevalence of CAMRSA in cases of soft tissue abscesses seen in the emergency departments of two major military hospitals.

Out-of-hospital combat casualty care in the current war in Iraq.

Study Objective: We describe outcomes for battle casualties receiving initial treatment at a US Army consolidated battalion aid station augmented with emergency medicine practitioners, advanced medic treatment protocols, and active medical direction. Battalion aid stations are mobile facilities integral to combat units, providing initial phases of advanced trauma life support and then evacuation. The setting was a forward base in central Iraq, with units engaged in urban combat operations.

Reducing risk in emergency department wound management.

Although substantial dollar amounts are not involved, wound-care litigation constitutes a significant number of lawsuits to emergency medicine physicians, resulting in an increased drain on the physician's time and exposing the physician to all the psychosocial effects involved in the medicolegal process. The procedures outlined in this article-paying attention to wound-care principles, involving patients in the medical decision-making process, and ensuring appropriate medical follow-up-can, it is hoped, reduce the incidence of medical claims.

Calcium chloride before i.v. diltiazem in the management of atrial fibrillation.

Diltiazem is commonly used to treat atrial fibrillation or flutter (AFF) with rapid ventricular response (RVR). Although it is very effective for rate control, up to an 18% prevalence of reported diltiazem-induced hypotension [defined by systolic blood pressure (SBP) < 90 mm Hg], and a mean of 9.7% hypotension have been reported from several studies totaling over 450 patients.